Basic Information
| Provider Information | |||||||||
| NPI: | 1538159140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED ANESTHESIOLOGISTS OF FORT WAYNE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633260 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452633260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178026303 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 5734 COVENTRY LN | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604367875 | ||||||||
| FaxNumber: | 2604329812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | BALKENBUSCH | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2604367875 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 791051091 | 01 | IN | RAILROAD MEDICARE | OTHER | 100054220 | 05 | IN | MEDICAID | 100054220A | 05 | IN | MEDICAID |