NPIMap

Organization Active NPI

Il S Kwak MD Inc

  • Specialist
  • Fort Wayne, IN
National Provider Identifier
1134318447
Registry record updated Jul 8, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
01026132A Issued in IN
Legal business name
IL S KWAK MD INC
Practice address
2222 Timberbrook TRL
Fort Wayne, IN 46845-9530
Phone
(260) 637-3939
Fax
(260) 637-3939
NPI assigned
Oct 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 8, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Il S Kwak, M.D
Title
President
Phone
(260) 637-3939

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 01026132A IN Primary

Addresses

Primary practice location

2222 Timberbrook TRL
Fort Wayne, IN 46845-9530

Mailing address

2222 Timberbrook TRL
Fort Wayne, IN 46845
Phone (260) 637-3939

Other identifiers 1

IdentifierTypeStateIssuer
100054590AMedicaidIN

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1193097600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1278547200000",
    "number": "1134318447",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2222 TIMBERBROOK TRL",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "46845",
            "telephone_number": "260-637-3939",
            "fax_number": "260-637-3939"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2222 TIMBERBROOK TRL",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468459530",
            "telephone_number": "260-637-3939",
            "fax_number": "260-637-3939"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IL S KWAK MD INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-23",
        "last_updated": "2010-07-08",
        "status": "A",
        "authorized_official_last_name": "KWAK",
        "authorized_official_first_name": "IL",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "260-637-3939",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "IN",
            "license": "01026132A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100054590A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.