Healthcare Provider Details

I. General information

NPI: 1104026657
Provider Name (Legal Business Name): COLON-RECTAL SURGEONS OF FORT WAYNE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 W JEFFERSON BLVD SUITE 302
FORT WAYNE IN
46804-4128
US

IV. Provider business mailing address

7900 W JEFFERSON BLVD SUITE 302
FORT WAYNE IN
46804-4128
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-1900
  • Fax: 260-435-1800
Mailing address:
  • Phone: 260-435-1900
  • Fax: 260-435-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: LISA HAUSCHILD
Title or Position: BUSINESS MANAGER
Credential:
Phone: 260-609-3734