Healthcare Provider Details

I. General information

NPI: 1467597062
Provider Name (Legal Business Name): INDIANA PATHOLOGY CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 WEST JEFFERSON BLVD. PATHOLOGY DEPARTMENT
FORT WAYNE IN
46804
US

IV. Provider business mailing address

3240B MALLARD COVE LN
FORT WAYNE IN
46804-2883
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7154
  • Fax: 260-435-7633
Mailing address:
  • Phone: 260-432-5867
  • Fax: 260-436-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number50000730A
License Number StateIN

VIII. Authorized Official

Name: MR. MAX L DANIELS
Title or Position: CORPORATE MANAGER
Credential:
Phone: 260-432-5867