MEDICARE: NORTHEAST OBSTETRICS & GYNECOLOGY, LLC

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1033374673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST OBSTETRICS & GYNECOLOGY, LLC

Provider Business Mailing Address
First Line	:	8028 CARNEGIE BLVD
Second Line	:	SUITE 200
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5787
Country	:	US
Telephone Number	:	260-422-7455
Fax Number	:	260-755-6233

Provider Business Practice Location Address
First Line	:	8028 CARNEGIE BLVD
Second Line	:	SUITE 200
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5787
Country	:	US
Telephone Number	:	260-422-7455
Fax Number	:	260-755-6233

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	TAMI A FURNISS
Credential	:
Telephone Number	:	260-426-7755

Provider Enumeration Date	:	07/23/2008
Last Update Date	:	07/23/2008

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