MEDICARE: FORT WAYNE MEDICAL LABORATORY CORPORATION

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	246RM2200X	Medical Laboratory Technician	50000070A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285610733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WAYNE MEDICAL LABORATORY CORPORATION

Provider Business Mailing Address
First Line	:	2470 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5406
Country	:	US
Telephone Number	:	260-424-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	2470 LAKE AVE
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46805-5406
Country	:	US
Telephone Number	:	260-424-2195
Fax Number	:

Authorized Official
Title or Position	:	LABORATORY DIRECTOR
Name	:	SEUNG S KIM
Credential	:	MD., PHD
Telephone Number	:	260-373-3657

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	03/01/2012

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