Provider Demographics
NPI:1811941024
Name:NORTHEAST OBSTETRICS & GYNECOLOGY, LLC
Entity type:Organization
Organization Name:NORTHEAST OBSTETRICS & GYNECOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FURNISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-426-7755
Mailing Address - Street 1:11123 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1707
Mailing Address - Country:US
Mailing Address - Phone:260-422-7455
Mailing Address - Fax:260-424-9356
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-422-7455
Practice Address - Fax:260-424-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001834A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100055270AMedicaid
IN100055270AMedicaid