Healthcare Provider Details

I. General information

NPI: 1083684948
Provider Name (Legal Business Name): CARDIOVASCULAR ASSOCIATES OF NORTHEASTERN INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 W JEFFERSON BLVD SUITE 303
FT WAYNE IN
46804-4128
US

IV. Provider business mailing address

7900 W JEFFERSON BLVD SUITE 303
FT WAYNE IN
46804-4128
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-6098
  • Fax: 260-436-3173
Mailing address:
  • Phone: 260-436-6098
  • Fax: 260-436-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN CSICSKO
Title or Position: OWNER
Credential: MD
Phone: 260-436-6098