MEDICARE: DIABETIC SPECIALISTS, INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000097484	OTHER	IN	ANTHEM PROVIDER NUMBER

General Provider Information

NPI Number	:	1598764284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETIC SPECIALISTS, INC

Provider Business Mailing Address
First Line	:	811 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6711
Country	:	US
Telephone Number	:	260-497-0912
Fax Number	:	260-497-0704

Provider Business Practice Location Address
First Line	:	811 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6711
Country	:	US
Telephone Number	:	260-497-0912
Fax Number	:	260-497-0704

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MS. AMANDA NICOLE BEGLEY
Credential	:
Telephone Number	:	260-497-0912

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	08/22/2020

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