Provider Demographics
NPI:1265870588
Name:KINNE, ROBERT JAMES (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:KINNE
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 1:1801 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1505
Mailing Address - Country:US
Mailing Address - Phone:515-282-5640
Mailing Address - Fax:515-282-2332
Practice Address - Street 1:7201 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2228
Practice Address - Country:US
Practice Address - Phone:260-432-1800
Practice Address - Fax:260-432-1804
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-09
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081602A208100000X
IAR-9785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300022826Medicaid
IN249490007OtherMEDICAID