MEDICARE: CENTER FOR COLON AND RECTAL CARE 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	208C00000X	Colon & Rectal Surgery Physician

General Provider Information

NPI Number	:	1568795409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR COLON AND RECTAL CARE LLC

Provider Business Mailing Address
First Line	:	12012 WOOD GLEN DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-4515
Country	:	US
Telephone Number	:	260-672-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	12012 WOOD GLEN DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-4515
Country	:	US
Telephone Number	:	260-672-1719
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	NADINE L. FLOYD
Credential	:	MD
Telephone Number	:	260-672-1719

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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