MEDICARE: FORT WAYNE ENDOSCOPY CENTER 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	261QE0800X	Endoscopy Clinic/Center	010098	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010098	OTHER	IN	STATE LICENSE
2	000000285559	OTHER		ANTHEM BCBS
3	15D1009484	OTHER		CLIA CERTIFICATE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548267024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WAYNE ENDOSCOPY CENTER LLC

Provider Business Mailing Address
First Line	:	3415 HOBSON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1617
Country	:	US
Telephone Number	:	260-266-9076
Fax Number	:	260-266-9071

Provider Business Practice Location Address
First Line	:	3415 HOBSON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1617
Country	:	US
Telephone Number	:	260-482-8001
Fax Number	:	260-471-7444

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	REBECCA TRIMBUR
Credential	:
Telephone Number	:	260-266-9075

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	03/07/2023

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