MEDICARE: MATTHEW ENGMAN

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	246ZE0600X	Electroneurodiagnostic Specialist/Technologist	1686	IN

General Provider Information

NPI Number	:	1205110392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW ENGMAN

Provider Business Mailing Address
First Line	:	5917 HALLOWELL PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5917 HALLOWELL PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6214
Country	:	US
Telephone Number	:	260-486-8133
Fax Number	:

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

Provider Enumeration Date	:	10/06/2011
Last Update Date	:	10/06/2011

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