Basic Information
| Provider Information | |||||||||
| NPI: | 1376533158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6610 MUTUAL DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468254236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Practice Location | |||||||||
| Address1: | 2514 E DUPONT RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | HILTY | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2604848830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | CA4536 | 01 | IN | MEDICARE RR | OTHER | 100053330A | 05 | IN | MEDICAID |