Provider Demographics
NPI:1356764419
Name:NORTHEAST INDIANA GENETICS, LLC
Entity type:Organization
Organization Name:NORTHEAST INDIANA GENETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-482-3886
Mailing Address - Street 1:7230 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2209
Mailing Address - Country:US
Mailing Address - Phone:260-482-3886
Mailing Address - Fax:260-482-1910
Practice Address - Street 1:7230 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2209
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:2014-01-27
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01022953AOtherPHYSICIAN MEDICAL LICENSING