Provider Demographics
NPI:1114950292
Name:MGFW SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MGFW SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-2297
Mailing Address - Street 1:PO BOX 2594
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2594
Mailing Address - Country:US
Mailing Address - Phone:260-432-2297
Mailing Address - Fax:260-434-6420
Practice Address - Street 1:7916 W. JEFFERSON BLVD.
Practice Address - Street 2:STE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00220062OtherMEDICARE - RAILROAD
IN000000372266OtherANTHEM
IN68579OtherAAAHC
INZG6040Medicare ID - Type Unspecified