Healthcare Provider Details

I. General information

NPI: 1730165242
Provider Name (Legal Business Name): FORT WAYNE CARDIOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date: 08/09/2007
Reactivation Date: 10/11/2007

III. Provider practice location address

208 COLUMBUS ST
HICKSVILLE OH
43526
US

IV. Provider business mailing address

PO BOX 11829
FORT WAYNE IN
46861-1829
US

V. Phone/Fax

Practice location:
  • Phone: 260-481-4700
  • Fax: 260-481-4808
Mailing address:
  • Phone: 260-481-4700
  • Fax: 260-481-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: POLLY BALOSKI
Title or Position: BILLING MANAGER
Credential:
Phone: 260-481-4700