Provider Demographics
NPI:1538159140
Name:ASSOCIATED ANESTHESIOLOGISTS OF FORT WAYNE PC
Entity type:Organization
Organization Name:ASSOCIATED ANESTHESIOLOGISTS OF FORT WAYNE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NATIONAL CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-715-5000
Mailing Address - Street 1:PO BOX 843603
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-3603
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6435 W JEFFERSON BLVD # 434
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6203
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:260-432-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017278Medicaid
OH0078204Medicaid
KY7100998850Medicaid
IN300024710Medicaid
KY7100998980Medicaid