MEDICARE: CARDIOSOM OF FT. WAYNE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)

General Provider Information

NPI Number	:	1003813692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOSOM OF FT. WAYNE, INC

Provider Business Mailing Address
First Line	:	615 W CARMEL DR
Second Line	:	STE 100
City	:	CARMEL
State	:	IN
Zip	:	46032-5504
Country	:	US
Telephone Number	:	317-706-1080
Fax Number	:	317-706-1022

Provider Business Practice Location Address
First Line	:	1625 MAGNAVOX WAY
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46804-1535
Country	:	US
Telephone Number	:	888-857-5337
Fax Number	:	260-459-9247

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KEVIN PAUL GREISL
Credential	:
Telephone Number	:	317-706-1080

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	08/22/2020

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