Provider Demographics
NPI:1548267024
Name:FORT WAYNE ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:FORT WAYNE ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIMBUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-266-9075
Mailing Address - Street 1:3415 HOBSON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1617
Mailing Address - Country:US
Mailing Address - Phone:260-266-9076
Mailing Address - Fax:260-266-9071
Practice Address - Street 1:3415 HOBSON RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1617
Practice Address - Country:US
Practice Address - Phone:260-482-8001
Practice Address - Fax:260-471-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010098261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN010098OtherSTATE LICENSE
000000285559OtherANTHEM BCBS
15D1009484OtherCLIA CERTIFICATE
IN200431310AMedicaid
IN200431310AMedicaid
000000285559OtherANTHEM BCBS