Provider Demographics
NPI:1144275629
Name:FOUNDATION SURGERY AFFILIATE OF FORT WAYNE, LLC
Entity type:Organization
Organization Name:FOUNDATION SURGERY AFFILIATE OF FORT WAYNE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:260-266-9313
Mailing Address - Street 1:8004 CARNEGIE BLVD.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5785
Mailing Address - Country:US
Mailing Address - Phone:260-434-3600
Mailing Address - Fax:260-434-3680
Practice Address - Street 1:8004 CARNEGIE BLVD.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5785
Practice Address - Country:US
Practice Address - Phone:260-434-3600
Practice Address - Fax:260-434-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INZG7040Medicare PIN