Healthcare Provider Details

I. General information

NPI: 1316500358
Provider Name (Legal Business Name): BRIAN COMMISKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

608 UNION CHAPEL RD
FORT WAYNE IN
46845-9357
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-1000
  • Fax:
Mailing address:
  • Phone: 260-498-2020
  • Fax: 260-498-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02006753A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: