Basic Information
| Provider Information | |||||||||
| NPI: | 1225684368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE VASCULAR CARE LLC | ||||||||
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| OtherOrganizationName: | NEPHROLOGY ASSOCIATES OF NORTHERN INDIANA PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72322 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441920002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305735000 | ||||||||
| FaxNumber: | 6303680280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1833 MAGNAVOX WAY # 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609180997 | ||||||||
| FaxNumber: | 2604367665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | PHIPPS | ||||||||
| AuthorizedOfficialFirstName: | CHARISSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTOR | ||||||||
| AuthorizedOfficialTelephone: | 6309745236 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.