Healthcare Provider Details

I. General information

NPI: 1003813692
Provider Name (Legal Business Name): CARDIOSOM OF FT. WAYNE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 MAGNAVOX WAY
FT WAYNE IN
46804-1535
US

IV. Provider business mailing address

615 W CARMEL DR STE 100
CARMEL IN
46032-5504
US

V. Phone/Fax

Practice location:
  • Phone: 888-857-5337
  • Fax: 260-459-9247
Mailing address:
  • Phone: 317-706-1080
  • Fax: 317-706-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN PAUL GREISL
Title or Position: PRESIDENT
Credential:
Phone: 317-706-1080