Organization
FORT WAYNE ENDOSCOPY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REBECCA TRIMBUR (ADMINISTRATOR)
(260) 266-9075
Entity
Organization
Contact information
Practice address
3415 HOBSON RD, FORT WAYNE, IN 46805-1617
(260) 482-8001
(260) 471-7444
Mailing address
3415 HOBSON RD, FORT WAYNE, IN 46805-1617
(260) 266-9076
(260) 266-9071
Taxonomy
Speciality
Code
Description
License number
State
261QE0800X
Endoscopy Clinic/Center
Primary
010098
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000285559
ANTHEM BCBS
—
01
—
010098
STATE LICENSE
IN
01
—
15D1009484
CLIA CERTIFICATE
—
05
—
200431310A
—
IN
Enumeration date
06/30/2005
Last updated
03/07/2023
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