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General NPI Number Information
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NPI Number | 1821133901
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Entity Type | Organization
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Legal Business Name | FORT WAYNE GI PATHOLOGY SERVICES, PC, INC.
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7950 W JEFFERSON BLVD GI PATHOLOGY
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City | FORT WAYNE
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State | IN
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Zip | 46804-4140
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Country | US
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Telephone | 260-435-7154
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Fax | 260-435-7633
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Provider Business Mailing Address
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Address Line | 6110 CONSTITUTION DR SUITE 112
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City | FORT WAYNE
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State | IN
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Zip | 46804-1556
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Country | US
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Telephone | 260-432-5867
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Fax | 260-436-9013
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Authorized Official
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Title or Position | CORPORATE MANAGER
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Name | MR. MAX L DANIELS
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Credential |
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Telephone | 260-432-5867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 50004501A
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License Number State | IN
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