Healthcare Provider Details

I. General information

NPI: 1114950292
Provider Name (Legal Business Name): MGFW SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 W. JEFFERSON BLVD. STE 100
FORT WAYNE IN
46804
US

IV. Provider business mailing address

PO BOX 2594
FORT WAYNE IN
46801-2594
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-2297
  • Fax: 260-434-6420
Mailing address:
  • Phone: 260-432-2297
  • Fax: 260-434-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

Name: MR. JOEL R SAUER
Title or Position: CEO
Credential:
Phone: 260-432-2297