Provider Demographics
NPI:1104026657
Name:COLON-RECTAL SURGEONS OF FORT WAYNE, PC
Entity Type:Organization
Organization Name:COLON-RECTAL SURGEONS OF FORT WAYNE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-609-3734
Mailing Address - Street 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-435-1900
Mailing Address - Fax:260-435-1800
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-435-1900
Practice Address - Fax:260-435-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN230430Medicare PIN