Basic Information
| Provider Information | |||||||||
| NPI: | 1508945809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE UROLOGY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1818 CAREW ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604828681 | ||||||||
| FaxNumber: | 2603734699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 CAREW ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604828681 | ||||||||
| FaxNumber: | 2603734699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | HIMMELEIN | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2604828681 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 100050350 | 05 | IN | MEDICAID |