Basic Information
| Provider Information | |||||||||
| NPI: | 1669458733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE CARDIOLOGY CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11829 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468611829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604814700 | ||||||||
| FaxNumber: | 2604814808 | ||||||||
| Practice Location | |||||||||
| Address1: | 11558 SR 111 | ||||||||
| Address2: | |||||||||
| City: | PAULDING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604814700 | ||||||||
| FaxNumber: | 2604814808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/09/2007 | ||||||||
| NPIReactivationDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | DUSMAN | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2604814700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORT WAYNE CARDIOLOGY CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200425420M | 05 | IN | MEDICAID | CK8615 | 01 | OH | RR MEDICARE | OTHER |