Healthcare Provider Details

I. General information

NPI: 1740595891
Provider Name (Legal Business Name): FORT WAYNE ORTHOPAEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 ORTHOPEDIC DR.
WARSAW IN
46582-3905
US

IV. Provider business mailing address

PO BOX 2526
FORT WAYNE IN
46801-2526
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8686
  • Fax: 260-432-5075
Mailing address:
  • Phone: 260-436-8686
  • Fax: 260-432-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number50002482
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number50002482
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number50002482
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number50002482
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number50002482
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number50002482
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50002482
License Number StateIN
# 8
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50002482
License Number StateIN

VIII. Authorized Official

Name: JERALD L COOPER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 260-436-8686