Healthcare Provider Details

I. General information

NPI: 1295905529
Provider Name (Legal Business Name): SPINE TECHNOLOGY AND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3898 NEW VISION DR SUITE B
FORT WAYNE IN
46845-1718
US

IV. Provider business mailing address

3898 NEW VISION DR SUITE B
FORT WAYNE IN
46845-1718
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 Code2081P2900X
TaxonomyPain Medicine (Physical 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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH FORTIN
Title or Position: PHYSICIAN OWNER
Credential: DO
Phone: 260-459-7313