MEDICARE: NORTHEAST INDIANA UROLOGY, P.C.

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972638955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST INDIANA UROLOGY, P.C.

Provider Business Mailing Address
First Line	:	2512 E DUPONT RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1609
Country	:	US
Telephone Number	:	260-436-6667
Fax Number	:

Provider Business Practice Location Address
First Line	:	2512 E DUPONT RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1609
Country	:	US
Telephone Number	:	260-436-6667
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN BRINKMAN
Credential	:	MD
Telephone Number	:	260-436-6667

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	04/11/2013

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