Individual ProviderSampath Kumar Santhanam EthirajInternal MedicineAllopathic & Osteopathic PhysiciansPractice Address11109 Parkview Plaza Dr, Fort Wayne, IN 46845-1701(260) 672-6620PECOS EnrollmentBased on the most recent information from CMS, provider Sampath Kumar Santhanam Ethiraj is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1700033727Provider TypeIndividualFull NameSanthanam Ethiraj, Sampath KumarTitleDr.CredentialM.B.B.SGenderMaleSole ProprietorYesEnumeration Date8/20/2008Last Updated10/3/2022Contact InformationPractice LocationPractice Address11109 Parkview Plaza Dr, Fort Wayne, IN 46845-1701Phone(260) 672-6620Fax(260) 672-6639Mailing LocationMailing Address11109 Parkview Plaza Dr # 117, Fort Wayne, IN 46845-1701PhoneUnlisted PhoneFaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode207R00000XPrimaryDescriptionInternal MedicineAllopathic & Osteopathic PhysiciansLicense01072529AIndianaCode207R00000XDescriptionInternal MedicineAllopathic & Osteopathic PhysiciansLicense4301092338Michigan