Basic Information
| Provider Information | |||||||||
| NPI: | 1407855802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLY | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3926 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
| FaxNumber: | 2604585636 | ||||||||
| Practice Location | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604227455 | ||||||||
| FaxNumber: | 2604249356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01057955A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200446790 | 05 | IN | MEDICAID | 000000595614 | 01 | IN | ANTHEM | OTHER | 000000512001 | 01 | IN | ANTHEM PROVIDER ID# - WHC | OTHER | 200446790A | 05 | IN | MEDICAID |