Provider Demographics
NPI:1619958766
Name:MUSSELMAN, ROBERT H (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:MUSSELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1361
Mailing Address - Country:US
Mailing Address - Phone:260-747-6171
Mailing Address - Fax:260-478-5125
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1361
Practice Address - Country:US
Practice Address - Phone:260-478-5180
Practice Address - Fax:260-478-5185
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025416A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000831OtherMPLAN
IN100318090Medicaid
000000091874OtherBLUE CROSS BLUE SHIELD
1619OtherPHYSICIANS HEALTH PLAN
IN080121951OtherRAILROAD MEDICARE
INM400048096Medicare PIN
000000091874OtherBLUE CROSS BLUE SHIELD
IN080121951OtherRAILROAD MEDICARE
IN925510FMedicare PIN