Provider Demographics
NPI:1184635153
Name:FORT WAYNE MEDICAL EDUCATION PROGRAM
Entity Type:Organization
Organization Name:FORT WAYNE MEDICAL EDUCATION PROGRAM
Other - Org Name:THE FAMILY MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:260-423-2682
Mailing Address - Street 1:750 BROADWAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1412
Mailing Address - Country:US
Mailing Address - Phone:260-423-2682
Mailing Address - Fax:260-422-4326
Practice Address - Street 1:750 BROADWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1412
Practice Address - Country:US
Practice Address - Phone:260-423-2675
Practice Address - Fax:260-423-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100050650AMedicaid
IN100050650AMedicaid