Provider Demographics
NPI:1992395388
Name:IU HEALTH SOUTHWEST FORT WAYNE AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:IU HEALTH SOUTHWEST FORT WAYNE AMBULATORY SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUSAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-220-8912
Mailing Address - Street 1:950 N MERIDIAN ST STE 910
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1077
Mailing Address - Country:US
Mailing Address - Phone:317-805-2247
Mailing Address - Fax:
Practice Address - Street 1:4105 DICKE ROAD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:317-201-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical