MEDICARE: DUPONT OB-GYN

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	207V00000X	Obstetrics & Gynecology Physician	01035629	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000093382	OTHER	IN	ANTHEM BCBS

General Provider Information

NPI Number	:	1669487005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUPONT OB-GYN

Provider Business Mailing Address
First Line	:	11123 PARKVIEW PLAZA DR
Second Line	:	SUITE 204
City	:	FT WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	260-490-6260
Fax Number	:	260-490-6261

Provider Business Practice Location Address
First Line	:	11123 PARKVIEW PLAZA DR
Second Line	:	SUITE 204
City	:	FT WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	260-490-6260
Fax Number	:	260-490-6261

Authorized Official
Title or Position	:	OWNER
Name	:	ROSEMARY LEITCH
Credential	:	MD FACOG
Telephone Number	:	260-490-6260

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	12/11/2007

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