Healthcare Provider Details

I. General information

NPI: 1104446376
Provider Name (Legal Business Name): BENJAMIN JOEL KOERNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 N CLINTON ST
FORT WAYNE IN
46825-5886
US

IV. Provider business mailing address

5052 N CLINTON ST
FORT WAYNE IN
46825-5822
US

V. Phone/Fax

Practice location:
  • Phone: 604-848-5512
  • Fax: 260-482-5060
Mailing address:
  • Phone: 260-484-8551
  • Fax: 260-408-8012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02008273A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: