1215948971 NPI number — MIDWEST FERTILITY SPECIALISTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215948971 NPI number — MIDWEST FERTILITY SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST FERTILITY SPECIALISTS
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:
1215948971
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:
12188 A N MERIDIAN ST
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-571-1637
Provider Business Mailing Address Fax Number:
317-571-9483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2514 EAST DUPONT ROAD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-490-3456
Provider Business Practice Location Address Fax Number:
260-490-4319
Provider Enumeration Date:
08/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOLODZEJ
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
317-571-1637

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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