Provider Demographics
NPI:1992395388
Name:IU HEALTH SOUTHWEST FORT WAYNE AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:IU HEALTH SOUTHWEST FORT WAYNE AMBULATORY SURGERY CENTER LLC
Other - Org Name:IU HEALTH SURGERY CENTER FORT WAYNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-268-1000
Mailing Address - Street 1:10300 N ILLINOIS ST STE 2055
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1167
Mailing Address - Country:US
Mailing Address - Phone:317-201-1038
Mailing Address - Fax:
Practice Address - Street 1:4105 DICKE ROAD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:317-201-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical