Healthcare Provider Details

I. General information

NPI: 1437362076
Provider Name (Legal Business Name): DIVERIS ORTHOPEDICS AND SPORTS MEDICINE,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2562 WALTON BLVD
WARSAW IN
46582-6522
US

IV. Provider business mailing address

2562 WALTON BLVD
WARSAW IN
46582-6522
US

V. Phone/Fax

Practice location:
  • Phone: 219-263-8849
  • Fax: 219-476-0108
Mailing address:
  • Phone: 219-263-8849
  • Fax: 574-267-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number01040065A
License Number StateIN

VIII. Authorized Official

Name: JOHN M DIVERIS
Title or Position: PRESIDENT
Credential: MD
Phone: 219-263-8849