Healthcare Provider Details

I. General information

NPI: 1174554554
Provider Name (Legal Business Name): JOHN PHILLIP TYNDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S CALHOUN ST
FORT WAYNE IN
46802-5257
US

IV. Provider business mailing address

1717 S CALHOUN ST
FORT WAYNE IN
46802-5257
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-2641
  • Fax: 260-458-3093
Mailing address:
  • Phone: 260-458-2641
  • Fax: 260-458-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number01020200A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: