Healthcare Provider Details

I. General information

NPI: 1134318355
Provider Name (Legal Business Name): FORT WAYNE CARDIOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 CAREW ST
FORT WAYNE IN
46805-4705
US

IV. Provider business mailing address

PO BOX 11829
FORT WAYNE IN
46861-1829
US

V. Phone/Fax

Practice location:
  • Phone: 260-481-4700
  • Fax: 260-481-4808
Mailing address:
  • Phone: 260-481-4700
  • Fax: 260-481-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCY SCHROEDER
Title or Position: CFO
Credential:
Phone: 260-481-4700