Healthcare Provider Details

I. General information

NPI: 1619918026
Provider Name (Legal Business Name): QHG OF FORT WAYNE COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7333 W JEFFERSON BLVD
FORT WAYNE IN
46804-6280
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3843
  • Fax: 260-637-1601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA MUSIC
Title or Position: DIRECTOR, PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7377