MEDICARE: NORTHEAST MEDICAL ASSOCIATES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	50004246A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CJ8803	OTHER	IN	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1003807850	OTHER	IN	GROUP NPI
2	7795314	OTHER	IN	AETNA PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003807850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST MEDICAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	1234 E. DUPONT RD.
Second Line	:	SUITE 6
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-480-2600
Fax Number	:	260-496-8077

Provider Business Practice Location Address
First Line	:	1234 E. DUPONT RD.
Second Line	:	SUITE 6
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-480-2600
Fax Number	:	260-496-8077

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. KAREN SUE EVANS
Credential	:	M.D.
Telephone Number	:	260-480-2600

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	03/09/2011

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Directions to “NORTHEAST MEDICAL ASSOCIATES, PC ” Practice Location

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