Provider Demographics
NPI:1669458733
Name:FORT WAYNE CARDIOLOGY CORPORATION
Entity Type:Organization
Organization Name:FORT WAYNE CARDIOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-481-4700
Mailing Address - Street 1:PO BOX 11829
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46861-1829
Mailing Address - Country:US
Mailing Address - Phone:260-481-4700
Mailing Address - Fax:260-481-4808
Practice Address - Street 1:11558 SR 111
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879
Practice Address - Country:US
Practice Address - Phone:260-481-4700
Practice Address - Fax:260-481-4808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT WAYNE CARDIOLOGY CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-20
Last Update Date:2008-10-07
Deactivation Date:2007-08-09
Deactivation Code:
Reactivation Date:2007-10-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200425420MMedicaid
OHCK8615OtherRR MEDICARE
OHFO9331212Medicare PIN
OHCK8615Medicare PIN