MEDICARE: EVERSIDE HEALTH FORT WAYNE-W LUDWIG RD

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1861880890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERSIDE HEALTH FORT WAYNE-W LUDWIG RD

Provider Business Mailing Address
First Line	:	4651 CHARLOTTE PARK DR STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2932 W LUDWIG RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1328
Country	:	US
Telephone Number	:	260-755-1304
Fax Number	:	260-755-1306

Authorized Official
Title or Position	:	DIRECTOR OF RISK MANAGEMENT
Name	:	JILL JOHNSON PATTON
Credential	:
Telephone Number	:	704-936-5546

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	08/30/2023

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