MEDICARE: FAMILY HEALTH PRACTITIONERS, LLC

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	208D00000X	General Practice Physician		IN

General Provider Information

NPI Number	:	1801138102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY HEALTH PRACTITIONERS, LLC

Provider Business Mailing Address
First Line	:	909 RIVER OAK RUN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-3543
Country	:	US
Telephone Number	:	812-653-0312
Fax Number	:

Provider Business Practice Location Address
First Line	:	909 RIVER OAK RUN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-3543
Country	:	US
Telephone Number	:	812-653-0312
Fax Number	:

Authorized Official
Title or Position	:	N.P.
Name	:	TRACY JOHNSON
Credential	:	N.P.
Telephone Number	:	812-653-0312

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	03/25/2013

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