Provider Demographics
NPI:1568595999
Name:PEDIATRICS CENTER OF FORT WAYNE, P.C.
Entity Type:Organization
Organization Name:PEDIATRICS CENTER OF FORT WAYNE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDORIW
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA
Authorized Official - Phone:260-422-4096
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:#25A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-4096
Mailing Address - Fax:260-424-2551
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:#25A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-4096
Practice Address - Fax:260-424-2551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10137509208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty