MEDICARE: ORTHOPAEDICS NORTHEAST, PC

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	207X00000X	Orthopaedic Surgery Physician	50001907A	IN

General Provider Information

NPI Number	:	1467407114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDICS NORTHEAST, PC

Provider Business Mailing Address
First Line	:	5050 N CLINTON ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5822
Country	:	US
Telephone Number	:	260-484-8551
Fax Number	:	260-484-9603

Provider Business Practice Location Address
First Line	:	1169 N MAIN ST
Second Line	:	SUITE 7
City	:	BLUFFTON
State	:	IN
Zip	:	46714-1360
Country	:	US
Telephone Number	:	260-846-0700
Fax Number	:	260-846-7019

Authorized Official
Title or Position	:	CEO
Name	:	RAYMOND KUSISTO
Credential	:
Telephone Number	:	260-484-8551

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	08/22/2020

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