Provider Demographics
NPI:1598806937
Name:OBSTETRICS AND GYNECOLOGY ASSOCIATES OF FORT WAYNE PC
Entity Type:Organization
Organization Name:OBSTETRICS AND GYNECOLOGY ASSOCIATES OF FORT WAYNE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JYOTHIRMAI
Authorized Official - Middle Name:K
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-459-2113
Mailing Address - Street 1:7802 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4138
Mailing Address - Country:US
Mailing Address - Phone:260-459-2113
Mailing Address - Fax:260-459-6625
Practice Address - Street 1:7802 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4138
Practice Address - Country:US
Practice Address - Phone:260-459-2113
Practice Address - Fax:260-459-6625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000091644OtherANTHEM PIN
IN100082350AMedicaid
IN1734OtherPHP
IN200141300AMedicaid
IN1734OtherPHP
IN200141300AMedicaid
IN=========OtherTAX ID