=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922433614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIED PHYSICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2013
-----------------------------------------------------
Last Update Date | 12/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2510 E DUPONT RD STE 128
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46825-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-489-4656
-----------------------------------------------------
Fax | 260-489-8280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2510 E DUPONT RD STE 128
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46825-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-489-4656
-----------------------------------------------------
Fax | 260-489-8280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ISA S CANAVATI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 260-436-2416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 01036895A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------