Healthcare Provider Details

I. General information

NPI: 1295141380
Provider Name (Legal Business Name): GYNECOLOGIC ONCOLOGY OF NORTHEAST INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 CAREW ST SUITE 250
FORT WAYNE IN
46805-4788
US

IV. Provider business mailing address

PO BOX 307
ROANOKE IN
46783-0307
US

V. Phone/Fax

Practice location:
  • Phone: 260-437-4789
  • Fax:
Mailing address:
  • Phone: 260-437-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: IWONA PODZIELINSKI
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 260-437-4789