Provider Demographics
NPI:1679574024
Name:ALLISON, NATHAN KYLE (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:KYLE
Last Name:ALLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 UNION CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9357
Mailing Address - Country:US
Mailing Address - Phone:260-482-5091
Mailing Address - Fax:260-498-2029
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060499A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000364924OtherANTHEM
IN200519770Medicaid
OH2571560Medicaid
MI104874445Medicaid
000000031002OtherMPLAN
INI15809Medicare UPIN
P00241010Medicare ID - Type UnspecifiedRR MEDICARE
IN200519770Medicaid