Healthcare Provider Details

I. General information

NPI: 1528044005
Provider Name (Legal Business Name): FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E MAUMEE ST
ANGOLA IN
46703-2017
US

IV. Provider business mailing address

PO BOX 15099
FORT WAYNE IN
46885-5099
US

V. Phone/Fax

Practice location:
  • Phone: 260-668-4040
  • Fax: 260-668-3897
Mailing address:
  • Phone: 260-484-8830
  • Fax: 260-483-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANNE KRAHN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 260-969-7868