Healthcare Provider Details

I. General information

NPI: 1700846243
Provider Name (Legal Business Name): ORTHOPAEDICS NORTHEAST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N SAWYER RD
KENDALLVILLE IN
46755-2568
US

IV. Provider business mailing address

5050 N CLINTON ST
FORT WAYNE IN
46825-5822
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-8551
  • Fax: 260-484-9603
Mailing address:
  • Phone: 260-484-8551
  • Fax: 260-484-9603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50001907A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5001907A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5001907A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number50001907A
License Number StateIN

VIII. Authorized Official

Name: RAYMOND KUSISTO
Title or Position: CEO
Credential:
Phone: 260-484-8551