Provider Demographics
NPI:1619950185
Name:INDIANA WOUND CARE, P.C.
Entity Type:Organization
Organization Name:INDIANA WOUND CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-424-9000
Mailing Address - Street 1:PO BOX 10493
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46852-0493
Mailing Address - Country:US
Mailing Address - Phone:260-424-9000
Mailing Address - Fax:260-425-3029
Practice Address - Street 1:700 BROADWAY FL 2
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1402
Practice Address - Country:US
Practice Address - Phone:260-424-9000
Practice Address - Fax:260-425-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004525A2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200437440AMedicaid
INDA1057OtherMEDICARE RAILROAD
IN204200Medicare PIN
IN200437440AMedicaid