MEDICARE: ENT REALTY CORP

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	261QA1903X	Ambulatory Surgical Clinic/Center

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	:	1588640353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENT REALTY CORP

Provider Business Mailing Address
First Line	:	10021 DUPONT CIRCLE CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1604
Country	:	US
Telephone Number	:	260-426-8117
Fax Number	:	260-420-0817

Provider Business Practice Location Address
First Line	:	7900 W JEFFERSON BLVD
Second Line	:	SUITE 102
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4128
Country	:	US
Telephone Number	:	260-432-4368
Fax Number	:	260-436-6283

Authorized Official
Title or Position	:	CEO
Name	:	HOLLY THOMPSON
Credential	:
Telephone Number	:	260-207-1675

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	11/18/2021

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Directions to “ENT REALTY CORP ” Practice Location

Language	Start Address	Practice Location

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