Healthcare Provider Details

I. General information

NPI: 1912941196
Provider Name (Legal Business Name): RICHARD L GEORGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11141 PARKVIEW PLAZA DR STE 305
FORT WAYNE IN
46845-1715
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-8900
  • Fax: 260-266-8935
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number22388
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35.094071
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number01094175A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: