Melvin Susanto, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

01091229A Issued in IN

Practice address

12404 Lima Crossing Dr
Fort Wayne, IN 46818-0202

Phone

(260) 458-3740

Fax

(260) 458-3741

NPI assigned

Jun 15, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Family Practice

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Lutheran Medical Group LLCGroup PAC ID 4981751617, 251 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Dupont Hospital LLC Hospital, Fort Wayne, IN, CCN 150150
• Parkview Regional Medical Center Hospital, Fort Wayne, IN, CCN 150021

Merit-based Incentive Payment System (MIPS)

Final score

90.99 of 100Reported as apm

Quality

77.41

Promoting interoperability

100

Improvement activities

40

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: melvin.susanto.1@17223.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lutheran Medical Group LLC

  • Cardiovascular Disease Physician
  • Fort Wayne, IN
  • NPI 1164662805
  Medicare reassignment Care Compare group NPD
• Lutheran Medical Group LLC

  • Durable Medical Equipment & Medical Supplies
  • Fort Wayne, IN
  • NPI 1710275664
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Dupont Hospital LLC

  • General Acute Care Hospital
  • Fort Wayne, IN
  • NPI 1538110556
  Care Compare affiliation
• Parkview Hospital, Inc.

  • General Acute Care Hospital
  • Fort Wayne, IN
  • NPI 1366407603
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623715200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1725840000000",
    "number": "1558939629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6920 POINTE INVERNESS WAY STE 200",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468047934",
            "telephone_number": "260-458-3740",
            "fax_number": "260-458-3741"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12404 LIMA CROSSING DR",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468180202",
            "telephone_number": "260-458-3740",
            "fax_number": "260-458-3741"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUSANTO",
        "first_name": "MELVIN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-15",
        "last_updated": "2024-09-09",
        "certification_date": "2024-09-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01091229A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300052108",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "melvin.susanto@lutheranhealthnetwork.cernerdirect.com",
            "affiliation": "N",
            "endpointDescription": "DM",
            "address_1": "12404 Lima Crossing Dr",
            "city": "Fort Wayne",
            "state": "IN",
            "country_code": "US",
            "postal_code": "468180202",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Christina Surine
• Jill Elizabeth Surine
• Manoj R Suryawala, M.D
• Susan L. Delagrange
• Susan Tielker-Sharpe Counseling, LLC
• Matthew Robert Sutter, MD
• Alexandra Sutton, LCSW
• Alice Sutton
• Amy A Sutton, NP
• Crystal Sutton

• Family Medicine Physician in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Family Medicine Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.