Provider Demographics
NPI:1659549475
Name:FORT WAYNE MEDICAL INSTITUTE
Entity Type:Organization
Organization Name:FORT WAYNE MEDICAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-483-4433
Mailing Address - Street 1:4424 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6917
Mailing Address - Country:US
Mailing Address - Phone:260-483-4433
Mailing Address - Fax:260-483-4223
Practice Address - Street 1:4424 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-483-4433
Practice Address - Fax:260-483-4223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114911807OtherPROVIDER NPI
OH0963453Medicaid
HA0758179Medicare PIN
OHF0934902Medicare PIN
OH0963453Medicaid
F00547Medicare UPIN