Healthcare Provider Details

I. General information

NPI: 1376582544
Provider Name (Legal Business Name): MARCUS ERVIN RAINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

6635 COUNTY ROAD 427
AUBURN IN
46706-9619
US

V. Phone/Fax

Practice location:
  • Phone: 260-460-1347
  • Fax:
Mailing address:
  • Phone: 912-288-5681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01062393A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: