Provider Demographics
NPI:1760803712
Name:FRESENIUS MEDICAL CARE FORT WAYNE, LLC
Entity Type:Organization
Organization Name:FRESENIUS MEDICAL CARE FORT WAYNE, LLC
Other - Org Name:FRESENIUS MEDICAL CARE DEFIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1850 E 2ND ST STE 18461850
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2502
Mailing Address - Country:US
Mailing Address - Phone:419-782-9090
Mailing Address - Fax:419-782-3520
Practice Address - Street 1:1850 E 2ND ST STE 18461850
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2502
Practice Address - Country:US
Practice Address - Phone:419-782-9090
Practice Address - Fax:419-782-3520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-18
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH362665Medicare Oscar/Certification