Basic Information
| Provider Information | |||||||||
| NPI: | 1316550445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA UNIVERSITY HEALTH FORT WAYNE PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652828900 | ||||||||
| FaxNumber: | 3179631316 | ||||||||
| Practice Location | |||||||||
| Address1: | 7230 ENGLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602345400 | ||||||||
| FaxNumber: | 2602345410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | VANATOR | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3179633395 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.