Provider Demographics
NPI:1205056561
Name:WOMEN'S HEALTH ADVANTAGE
Entity type:Organization
Organization Name:WOMEN'S HEALTH ADVANTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPORRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-432-4400
Mailing Address - Street 1:2512 DUPONT ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-432-4400
Mailing Address - Fax:
Practice Address - Street 1:7635 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-432-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0832680001Medicare NSC