Provider Demographics
NPI:1295905529
Name:SPINE TECHNOLOGY AND REHABILITATION PC
Entity type:Organization
Organization Name:SPINE TECHNOLOGY AND REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:260-459-7313
Mailing Address - Street 1:3898 NEW VISION DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1718
Mailing Address - Country:US
Mailing Address - Phone:260-459-7313
Mailing Address - Fax:260-436-0628
Practice Address - Street 1:3898 NEW VISION DR
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1718
Practice Address - Country:US
Practice Address - Phone:260-459-7313
Practice Address - Fax:260-436-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1281330001Medicare NSC