Provider Demographics
NPI:1043644354
Name:FORT WAYNE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:FORT WAYNE MEDICAL CLINIC PC
Other - Org Name:FORT WAYNE OCCUPATIONAL MEDICAL CLINIC PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-471-5777
Mailing Address - Street 1:3537 N ANTHONY BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1423
Mailing Address - Country:US
Mailing Address - Phone:260-471-5777
Mailing Address - Fax:260-739-3927
Practice Address - Street 1:3537 N ANTHONY BLVD STE C
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1423
Practice Address - Country:US
Practice Address - Phone:260-471-5777
Practice Address - Fax:260-739-3927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059980A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty