Provider Demographics
NPI:1912998014
Name:NORTHEAST INDIANA COLON RECTAL SURGEONS PC
Entity Type:Organization
Organization Name:NORTHEAST INDIANA COLON RECTAL SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-489-8898
Mailing Address - Street 1:11141 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-489-8898
Mailing Address - Fax:260-373-4695
Practice Address - Street 1:11141 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-489-8898
Practice Address - Fax:260-373-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004032A208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2053852Medicaid
OH2053852Medicaid