Healthcare Provider Details

I. General information

NPI: 1881678860
Provider Name (Legal Business Name): NORTHEAST INDIANA GENETIC COUNSELING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11143 PARKVIEW PLAZA DR STE. 311
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

11143 PARKVIEW PLAZA DR STE. 311
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-3886
  • Fax: 260-482-1910
Mailing address:
  • Phone: 260-482-3886
  • Fax: 260-482-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number01022953
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number01022953
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01022953
License Number StateIN

VIII. Authorized Official

Name: MRS. PATRICIA I BADER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 260-482-3886