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General NPI Number Information
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NPI Number | 1225684368
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Entity Type | Organization
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Legal Business Name | FORT WAYNE VASCULAR CARE LLC
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Dates
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Enumeration Date | 08/14/2019
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Last Update Date | 02/04/2026
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Provider Practice Location Address
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Address Line | 1833 MAGNAVOX WAY # 100
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City | FORT WAYNE
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State | IN
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Zip | 46804-1539
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Country | US
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Telephone | 260-918-0997
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Fax | 260-436-7665
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Provider Business Mailing Address
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Address Line | 120 W 22ND ST SUITE 200
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City | OAK BROOK
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State | IL
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Zip | 60523-1563
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Country | US
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Telephone | 630-573-5000
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Fax | 630-368-0280
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Authorized Official
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Title or Position | MD
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Name | MANISH TANNA
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Credential |
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Telephone | 630-573-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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