MEDICARE: DR. GEORGE H KINNEBREW M.D.

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	2085R0202X	Diagnostic Radiology Physician	01032457	IN

General Provider Information

NPI Number	:	1992711576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE H KINNEBREW M.D.

Provider Business Mailing Address
First Line	:	3707 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1702
Country	:	US
Telephone Number	:	260-484-0850
Fax Number	:	260-484-5919

Provider Business Practice Location Address
First Line	:	3707 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46895-5602
Country	:	US
Telephone Number	:	260-484-0850
Fax Number	:	260-484-5919

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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