Provider Demographics
NPI:1790718765
Name:FORT WAYNE CARDIOVASCULAR SURGEON
Entity Type:Organization
Organization Name:FORT WAYNE CARDIOVASCULAR SURGEON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-483-6448
Mailing Address - Street 1:1818 CAREW STREEET
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805
Mailing Address - Country:US
Mailing Address - Phone:260-483-6448
Mailing Address - Fax:260-373-4167
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-483-6448
Practice Address - Fax:260-373-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000046A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN046240Medicare ID - Type UnspecifiedGROUP MEDICARE