Provider Demographics
NPI:1295749117
Name:FT WAYNE CARDIAC CENTER LLC
Entity type:Organization
Organization Name:FT WAYNE CARDIAC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-2297
Mailing Address - Street 1:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2588
Mailing Address - Country:US
Mailing Address - Phone:260-432-2297
Mailing Address - Fax:260-436-4380
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:STE. 120
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-436-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00098221OtherTRAVELERS MEDICARE
IN200860Medicare ID - Type Unspecified