Provider Demographics
NPI:1376533158
Name:FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC
Entity Type:Organization
Organization Name:FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GISSLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-484-8830
Mailing Address - Street 1:6610 MUTUAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4236
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:2514 E DUPONT RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1619
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCA4536OtherMEDICARE RR
IN100053330AMedicaid
INCA4536Medicare PIN
IN055770Medicare PIN
IN5547740001Medicare NSC