MEDICARE: FAWVER WALDO CLINIC LLP

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	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD0871	OTHER		RR MEDICARE

General Provider Information

NPI Number	:	1174536346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAWVER WALDO CLINIC LLP

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY
Second Line	:	SUITE 250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7926
Country	:	US
Telephone Number	:	260-436-4060
Fax Number	:	260-436-5713

Provider Business Practice Location Address
First Line	:	6920 POINTE INVERNESS WAY
Second Line	:	SUITE 250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7926
Country	:	US
Telephone Number	:	260-436-4060
Fax Number	:	260-436-5713

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	JAY D FAWVER
Credential	:	MD
Telephone Number	:	260-436-4060

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	09/11/2025

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