Provider Demographics
NPI:1083608327
Name:FORT WAYNE ORTHOPAEDICS, LLC SURGICENTER
Entity Type:Organization
Organization Name:FORT WAYNE ORTHOPAEDICS, LLC SURGICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-436-8686
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2526
Mailing Address - Country:US
Mailing Address - Phone:260-436-8686
Mailing Address - Fax:260-432-5075
Practice Address - Street 1:7601 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-8686
Practice Address - Fax:260-432-5075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002482A261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INZG0530Medicare ID - Type Unspecified