Healthcare Provider Details

I. General information

NPI: 1043130651
Provider Name (Legal Business Name): FORT WAYNE BRAIN & SPINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD STE 205B
FORT WAYNE IN
46804-0072
US

IV. Provider business mailing address

7910 W JEFFERSON BLVD STE 205B
FORT WAYNE IN
46804-0072
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAHNAWAZ QURESHI
Title or Position: OWNER
Credential: DO
Phone: 111-111-1111