Basic Information
| Provider Information | |||||||||
| NPI: | 1568595999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRICS CENTER OF FORT WAYNE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 LAKE AVE | ||||||||
| Address2: | #25A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604224096 | ||||||||
| FaxNumber: | 2604242551 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 LAKE AVE | ||||||||
| Address2: | #25A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604224096 | ||||||||
| FaxNumber: | 2604242551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FEDORIW | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2604224096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | B.A., M.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 10137509 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.