Healthcare Provider Details

I. General information

NPI: 1538159140
Provider Name (Legal Business Name): ASSOCIATED ANESTHESIOLOGISTS OF FORT WAYNE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 10/21/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 W JEFFERSON BLVD # 434
FORT WAYNE IN
46804-6203
US

IV. Provider business mailing address

PO BOX 843603
DALLAS TX
75284-3603
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7875
  • Fax: 260-432-9812
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY ANN JOLLEY
Title or Position: NATIONAL CREDENTIALING DIRECTOR
Credential:
Phone: 972-715-5000