Provider Demographics
NPI:1639239171
Name:FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY INC
Entity Type:Organization
Organization Name:FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-484-8830
Mailing Address - Street 1:2514 E DUPONT ROAD SUITE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1619
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:2514 E DUPONT ROAD SUITE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1619
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005894332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053330Medicaid
IN100053330Medicaid
IN055770Medicare ID - Type UnspecifiedGROUP