MEDICARE: TRISHA L. HOCKEMEYER RD

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	37001927A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000696175	OTHER	IN	ANTHEM
2	000000696201	OTHER	IN	ANTHEM
3	000000696204	OTHER	IN	ANTHEM
4	000000696195	OTHER	IN	ANTHEM
5	000000696205	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1528364247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISHA L. HOCKEMEYER RD

Provider Business Mailing Address
First Line	:	1234 E DUPONT RD
Second Line	:	SUITE 3
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-373-9965
Fax Number	:	260-458-5664

Provider Business Practice Location Address
First Line	:	8028 CARNEGIE BLVD
Second Line	:	SUITE 250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5787
Country	:	US
Telephone Number	:	260-755-6233
Fax Number	:	260-422-4125

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

Provider Enumeration Date	:	01/27/2011
Last Update Date	:	02/14/2011

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