MEDICARE: SPINE CENTER OF FORT WAYNE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1417297839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE CENTER OF FORT WAYNE

Provider Business Mailing Address
First Line	:	3417 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3417 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4830
Country	:	US
Telephone Number	:	260-387-6218
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	NATHAN SERMERSHEIM
Credential	:	D.C.
Telephone Number	:	260-387-6218

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	12/02/2014

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Directions to “SPINE CENTER OF FORT WAYNE ” Practice Location

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