Provider Demographics
NPI:1003813692
Name:CARDIOSOM OF FT. WAYNE, INC
Entity Type:Organization
Organization Name:CARDIOSOM OF FT. WAYNE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GREISL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-706-1080
Mailing Address - Street 1:615 W CARMEL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5504
Mailing Address - Country:US
Mailing Address - Phone:317-706-1080
Mailing Address - Fax:317-706-1022
Practice Address - Street 1:1625 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1535
Practice Address - Country:US
Practice Address - Phone:888-857-5337
Practice Address - Fax:260-459-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5067100001Medicare ID - Type Unspecified