Healthcare Provider Details

I. General information

NPI: 1245213263
Provider Name (Legal Business Name): SPINE TECHNOLOGY AND REHABILITATION, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3898 NEW VISION DR STE B
FORT WAYNE IN
46845-1719
US

IV. Provider business mailing address

3898 NEW VISION DR STE B
FORT WAYNE IN
46845-1719
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-7313
  • Fax: 260-436-0628
Mailing address:
  • Phone: 260-459-7313
  • Fax: 260-436-0628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10001306A
License Number StateIN

VIII. Authorized Official

Name: JOSEPH D. FORTIN
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 260-459-7313