Provider Demographics
NPI:1508945809
Name:FORT WAYNE UROLOGY INC.
Entity Type:Organization
Organization Name:FORT WAYNE UROLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIMMELEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-482-8681
Mailing Address - Street 1:1818 CAREW ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4788
Mailing Address - Country:US
Mailing Address - Phone:260-482-8681
Mailing Address - Fax:260-373-4699
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-482-8681
Practice Address - Fax:260-373-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100050350Medicaid
IN048010Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IN0450110001Medicare NSC
INCB5233Medicare PIN
IN048010Medicare PIN