Provider Demographics
NPI:1285610733
Name:FORT WAYNE MEDICAL LABORATORY CORPORATION
Entity type:Organization
Organization Name:FORT WAYNE MEDICAL LABORATORY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:260-373-3657
Mailing Address - Street 1:2470 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5406
Mailing Address - Country:US
Mailing Address - Phone:260-424-2195
Mailing Address - Fax:
Practice Address - Street 1:2470 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5406
Practice Address - Country:US
Practice Address - Phone:260-424-2195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000070A246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200402190AMedicaid
IN982550Medicare ID - Type Unspecified