MEDICARE: FORT WAYNE MEDICAL ONCOLOGY & HEMAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy	60005894A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1560247	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1215066949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WAYNE MEDICAL ONCOLOGY & HEMAT

Provider Business Mailing Address
First Line	:	PO BOX 15099
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46885-5099
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4402 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-969-7846
Fax Number	:	260-483-1734

Authorized Official
Title or Position	:	PHARMACY DIRECTOR
Name	:	TRACY MARAVILLA
Credential	:	PHARMD
Telephone Number	:	260-484-9660

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	05/03/2010

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Directions to “FORT WAYNE MEDICAL ONCOLOGY & HEMAT ” Practice Location

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