Provider Demographics
NPI:1780218115
Name:SURGERY CENTER OF FORT WAYNE
Entity Type:Organization
Organization Name:SURGERY CENTER OF FORT WAYNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:EHRET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-450-5441
Mailing Address - Street 1:1721 MAGNAVOX WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1537
Mailing Address - Country:US
Mailing Address - Phone:260-250-0001
Mailing Address - Fax:260-222-0002
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:317-450-5441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical