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General NPI Number Information
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NPI Number | 1568595999
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Entity Type | Organization
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Legal Business Name | PEDIATRICS CENTER OF FORT WAYNE, P.C.
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3030 LAKE AVE #25A
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City | FORT WAYNE
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State | IN
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Zip | 46805-5428
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Country | US
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Telephone | 260-422-4096
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Fax | 260-424-2551
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Provider Business Mailing Address
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Address Line | 3030 LAKE AVE #25A
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City | FORT WAYNE
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State | IN
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Zip | 46805-5428
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Country | US
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Telephone | 260-422-4096
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Fax | 260-424-2551
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. ELIZABETH FEDORIW
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Credential | B.A., M.A.
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Telephone | 260-422-4096
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 10137509
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License Number State | IN
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