=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679601132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN INDIANA ORTHOPAEDICS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 11/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 S LAKE PARK AVE STE 200
-----------------------------------------------------
City | HOBART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46342-6636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-947-5606
-----------------------------------------------------
Fax | 219-942-4742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 306
-----------------------------------------------------
City | DEMOTTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46310-0306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-947-5606
-----------------------------------------------------
Fax | 219-942-4742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GENE VICTOR FEDOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 219-947-5606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 01043359A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------