MEDICARE: DR. GERRY S EASTERDAY MD

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	207P00000X	Emergency Medicine Physician	01036101A	IN

General Provider Information

NPI Number	:	1073508461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERRY S EASTERDAY MD

Provider Business Mailing Address
First Line	:	3978 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1712
Country	:	US
Telephone Number	:	260-672-4680
Fax Number	:	260-672-4685

Provider Business Practice Location Address
First Line	:	3978 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1712
Country	:	US
Telephone Number	:	260-672-4680
Fax Number	:	260-672-4685

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	04/10/2014

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