Healthcare Provider Details

I. General information

NPI: 1396266219
Provider Name (Legal Business Name): KATHLEEN ANNE C. ROCCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/12/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 MARINERS DR
WARSAW IN
46582-7145
US

IV. Provider business mailing address

608 UNION CHAPEL RD
FORT WAYNE IN
46845-9357
US

V. Phone/Fax

Practice location:
  • Phone: 574-362-0000
  • Fax:
Mailing address:
  • Phone: 260-482-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.245013
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.135402
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01084471A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: