Provider Demographics
NPI:1053358614
Name:FORT WAYNE RETINA, P.C.
Entity type:Organization
Organization Name:FORT WAYNE RETINA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FINNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-433-0164
Mailing Address - Street 1:10300 N ILLINOIS ST STE 1050
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1168
Mailing Address - Country:US
Mailing Address - Phone:317-817-1822
Mailing Address - Fax:317-817-1898
Practice Address - Street 1:10300 N ILLINOIS ST STE 1050
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1168
Practice Address - Country:US
Practice Address - Phone:317-817-1822
Practice Address - Fax:317-817-1898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050629A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200218500Medicaid
IN200880960AMedicaid
INDG0850OtherMEDICARE RAILROAD
1225014848OtherNPI
IN200880960AMedicaid
G81270Medicare UPIN
IN165380CMedicare PIN