Provider Demographics
NPI:1619195815
Name:QHG OF FORT WAYNE, INC.
Entity Type:Organization
Organization Name:QHG OF FORT WAYNE, INC.
Other - Org Name:BUSINESS HEALTH CLINIC SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KONOW
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:260-435-7841
Mailing Address - Street 1:5932 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1677
Mailing Address - Country:US
Mailing Address - Phone:260-436-2273
Mailing Address - Fax:260-436-0804
Practice Address - Street 1:5932 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1677
Practice Address - Country:US
Practice Address - Phone:260-436-2273
Practice Address - Fax:260-436-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care