MEDICARE: QHG OF FORT WAYNE, INC.

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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1619195815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QHG OF FORT WAYNE, INC.

Provider Business Mailing Address
First Line	:	5932 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1677
Country	:	US
Telephone Number	:	260-436-2273
Fax Number	:	260-436-0804

Provider Business Practice Location Address
First Line	:	5932 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1677
Country	:	US
Telephone Number	:	260-436-2273
Fax Number	:	260-436-0804

Authorized Official
Title or Position	:	CEO
Name	:	MR. DANIEL R KONOW
Credential	:	PA
Telephone Number	:	260-435-7841

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	08/22/2020

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