Provider Demographics
NPI:1679601132
Name:NORTHERN INDIANA ORTHOPAEDICS, PC
Entity Type:Organization
Organization Name:NORTHERN INDIANA ORTHOPAEDICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:FEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-947-5606
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0306
Mailing Address - Country:US
Mailing Address - Phone:219-947-5606
Mailing Address - Fax:219-942-4742
Practice Address - Street 1:1400 S LAKE PARK AVE STE 200
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6636
Practice Address - Country:US
Practice Address - Phone:219-947-5606
Practice Address - Fax:219-942-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043359A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000184715OtherBLUE CROSS BLUE SHIELD
IN408560Medicare PIN