Provider Demographics
NPI:1649221680
Name:REHAB HOSPITAL OF FORT WAYNE LLC
Entity Type:Organization
Organization Name:REHAB HOSPITAL OF FORT WAYNE LLC
Other - Org Name:REHAB HOSPITAL OF FORT WAYNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-4503
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:LEGAL
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:
Practice Address - Street 1:7970 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-006245-1283X00000X, 283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153030OtherMEDICARE
IN200097450AMedicaid