1790718765 NPI number — FORT WAYNE CARDIOVASCULAR SURGEON

Table of content: (NPI 1790718765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790718765 NPI number — FORT WAYNE CARDIOVASCULAR SURGEON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WAYNE CARDIOVASCULAR SURGEON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790718765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 CAREW STREEET
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-483-6448
Provider Business Mailing Address Fax Number:
260-373-4167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11123 PARKVIEW PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-483-6448
Provider Business Practice Location Address Fax Number:
260-373-4167
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT/PARTNER
Authorized Official Telephone Number:
260-483-6448

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  50000046A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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