Provider Demographics
NPI:1821133901
Name:FORT WAYNE GI PATHOLOGY SERVICES, PC, INC.
Entity Type:Organization
Organization Name:FORT WAYNE GI PATHOLOGY SERVICES, PC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-5867
Mailing Address - Street 1:6110 CONSTITUTION DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1556
Mailing Address - Country:US
Mailing Address - Phone:260-432-5867
Mailing Address - Fax:260-436-9013
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:GI PATHOLOGY
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7154
Practice Address - Fax:260-435-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004501A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200430Medicare ID - Type Unspecified