Basic Information
| Provider Information | |||||||||
| NPI: | 1669487005 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DUPONT OB-GYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604906260 | ||||||||
| FaxNumber: | 2604906261 | ||||||||
| Practice Location | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604906260 | ||||||||
| FaxNumber: | 2604906261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | LEITCH | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2604906260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD FACOG | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01035629 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000093382 | 01 | IN | ANTHEM BCBS | OTHER |