Healthcare Provider Details

I. General information

NPI: 1912998014
Provider Name (Legal Business Name): NORTHEAST INDIANA COLON RECTAL SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11141 PARKVIEW PLAZA DR SUITE 310
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

11141 PARKVIEW PLAZA DR SUITE 310
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-8898
  • Fax: 260-373-4695
Mailing address:
  • Phone: 260-489-8898
  • Fax: 260-373-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number50004032A
License Number StateIN

VIII. Authorized Official

Name: PAUL J. RAIMAN
Title or Position: OWNER/PRACTITIONER
Credential: M.D.
Phone: 260-489-8898