MEDICARE: MARIA KRACH R.D.

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	133V00000X	Registered Dietitian	37000910	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000355285	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1013976950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA KRACH R.D.

Provider Business Mailing Address
First Line	:	2515 MILL POND CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7757
Country	:	US
Telephone Number	:	260-436-1312
Fax Number	:	260-436-1312

Provider Business Practice Location Address
First Line	:	2515 MILL POND CT.
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804
Country	:	US
Telephone Number	:	260-436-1312
Fax Number	:	260-436-1312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	05/05/2011

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