Basic Information
| Provider Information | |||||||||
| NPI: | 1437263944 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CRISMAN | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | MEDPARTNERS, ATTN: MEGAN FORTNEY | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793515 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S BROAD ST | ||||||||
| Address2: | STE. B | ||||||||
| City: | FREMONT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467372114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604959803 | ||||||||
| FaxNumber: | 2604951238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01030303A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100225590 | 05 | IN | MEDICAID | 3117175 | 05 | OH | MEDICAID | 000000329797 | 01 | IN | ANTHEM BCBS OF INDIANA | OTHER | 4048082 | 01 | AETNA | OTHER |