Provider Demographics
NPI:1306037254
Name:CAREFIRST OF FORTWAYNE INC
Entity Type:Organization
Organization Name:CAREFIRST OF FORTWAYNE INC
Other - Org Name:ADVANCED HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:260-373-1600
Mailing Address - Street 1:3204 CONGRESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-4417
Mailing Address - Country:US
Mailing Address - Phone:260-373-1600
Mailing Address - Fax:260-373-1601
Practice Address - Street 1:718 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1006
Practice Address - Country:US
Practice Address - Phone:260-624-3093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000127A332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN69000127AOtherPHARMACY LICENSE
IN69000127AOtherPHARMACY LICENSE