MEDICARE: QHG OF FORT WAYNE COMPANY 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1083656573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QHG OF FORT WAYNE COMPANY LLC

Provider Business Mailing Address
First Line	:	7100 COMMERCE WAY
Second Line	:	SUITE 180
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-2829
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3717 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8424
Country	:	US
Telephone Number	:	260-486-7334
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PROVIDER ENROLLMENT
Name	:	DEBBIE T BREWER
Credential	:
Telephone Number	:	615-465-7626

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	02/27/2008

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Directions to “QHG OF FORT WAYNE COMPANY LLC ” Practice Location

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