Basic Information
| Provider Information | |||||||||
| NPI: | 1205989159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE CARDIOVASCULAR ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604836448 | ||||||||
| FaxNumber: | 2603734167 | ||||||||
| Practice Location | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604836448 | ||||||||
| FaxNumber: | 2603734167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LLOYD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2604836448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.