Basic Information
| Provider Information | |||||||||
| NPI: | 1285610733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE MEDICAL LABORATORY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2470 LAKE AVE | ||||||||
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| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604242195 | ||||||||
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| Address1: | 2470 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604242195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | SEUNG | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2603733657 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD., PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246RM2200X | 50000070A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Pathology | Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 200402190A | 05 | IN | MEDICAID |