Healthcare Provider Details

I. General information

NPI: 1316065766
Provider Name (Legal Business Name): RHEUMATOLOGY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 EAST DUPONT ROAD SUITE 5
FORT WAYNE IN
46825-1545
US

IV. Provider business mailing address

1234 EAST DUPONT ROAD SUITE 5
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-1666
  • Fax: 260-489-3255
Mailing address:
  • Phone: 260-489-1666
  • Fax: 260-489-3255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01022346
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01043264
License Number StateIN

VIII. Authorized Official

Name: MR. KENNETH A SMITH
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 260-489-1666