Provider Demographics
NPI:1730277583
Name:FORT WAYNE DERMATOLOGY CONSULTANTS INC
Entity type:Organization
Organization Name:FORT WAYNE DERMATOLOGY CONSULTANTS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:SARKISIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-8000
Mailing Address - Street 1:7881 CARNEGIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5792
Mailing Address - Country:US
Mailing Address - Phone:260-436-8000
Mailing Address - Fax:260-432-5587
Practice Address - Street 1:7881 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5792
Practice Address - Country:US
Practice Address - Phone:260-436-8000
Practice Address - Fax:260-432-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200459670AMedicaid
4463426OtherAETNA
DA4850OtherMEDICARE RAIL ROAD
IN204090Medicare PIN