Provider Demographics
NPI:1881678860
Name:NORTHEAST INDIANA GENETIC COUNSELING CENTER INC
Entity Type:Organization
Organization Name:NORTHEAST INDIANA GENETIC COUNSELING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-482-3886
Mailing Address - Street 1:11143 PARKVIEW PLAZA DR
Mailing Address - Street 2:STE. 311
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-482-3886
Mailing Address - Fax:260-482-1910
Practice Address - Street 1:11143 PARKVIEW PLAZA DR
Practice Address - Street 2:STE. 311
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-482-3886
Practice Address - Fax:260-482-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022953207SC0300X, 207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical CytogeneticsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100080650AMedicaid
IN100360290AMedicaid
IN100360290AMedicaid
IN134660AMedicare PIN