NPIMap

Organization Active NPI

Fort Wayne Medical Education Program

  • Family Medicine Physician
  • Fort Wayne, IN
National Provider Identifier
1184635153
Registry record updated Apr 20, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
FORT WAYNE MEDICAL EDUCATION PROGRAM
Practice address
750 Broadway
Suite 350
Fort Wayne, IN 46802-1412
Phone
(260) 423-2675
Fax
(260) 423-6621
NPI assigned
Aug 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 20, 2015

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

Authorized official

Name
Kimberly Harris, COO
Title
Chief Operating Officer
Phone
(260) 423-2682

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

750 Broadway
Suite 350
Fort Wayne, IN 46802-1412

Mailing address

750 Broadway
Suite 150
Fort Wayne, IN 46802-1412
Phone (260) 423-2682

Other identifiers 1

IdentifierTypeStateIssuer
100050650AMedicaidIN

Other names 1

  • The Family Medicine Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040218000034 IN Part B Supplier - Clinic/Group Practice 2860387933 Receives reassigned benefits from 12 practitioners
Practice locations: Fort Wayne, IN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D0358144Ft Wayne Medical Education/Family Practice Center750 Broadway Ste 350, Fort Wayne, IN 46802Provider-performed microscopyJan 7, 2028

National Provider Directory

National Provider Directory

Locations

750 Broadway
Fort Wayne, IN 46802
Phone (260) 399-4249

750 Broadway
Ste 250
Fort Wayne, IN 46802
Phone (260) 423-2675

750 Broadway
Ste 150
Fort Wayne, IN 46802
Phone (260) 423-2675

Practitioners & affiliated clinicians

Practitioners 115

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 115

NPI Registry JSON

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

{
    "created_epoch": "1155254400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1429488000000",
    "number": "1184635153",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 BROADWAY",
            "address_2": "SUITE 150",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468021412",
            "telephone_number": "260-423-2682",
            "fax_number": "260-422-4326"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 BROADWAY",
            "address_2": "SUITE 350",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468021412",
            "telephone_number": "260-423-2675",
            "fax_number": "260-423-6621"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE MEDICAL EDUCATION PROGRAM",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-11",
        "last_updated": "2015-04-20",
        "status": "A",
        "authorized_official_last_name": "HARRIS",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "260-423-2682",
        "authorized_official_credential": "COO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100050650A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Family Medicine Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Apr 20, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.