NPIMap

Organization Active NPI

Fort Wayne Medical Oncology & Hemat

  • Clinic Pharmacy
  • Fort Wayne, IN
National Provider Identifier
1215066949
Registry record updated May 3, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic PharmacyTaxonomy code 3336C0002X
License
60005894A Issued in IN
Legal business name
FORT WAYNE MEDICAL ONCOLOGY & HEMAT
Practice address
4402 E State Blvd
Fort Wayne, IN 46815-6917
Phone
(260) 969-7846
Fax
(260) 483-1734
NPI assigned
Mar 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 3, 2010

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

Authorized official

Name
Tracy Maravilla, PHARMD
Title
Pharmacy Director
Phone
(260) 484-9660

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic Pharmacy 3336C0002X 60005894A IN Primary

Addresses

Primary practice location

4402 E State Blvd
Fort Wayne, IN 46815-6917

Mailing address

PO Box 15099
Fort Wayne, IN 46885-5099

Other identifiers 2

IdentifierTypeStateIssuer
200544860AMedicaidIN
1560247OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names 1

  • FT WAYNE MED ONCOLOGY AND HEMATOLOGY Doing business as

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1173139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1272844800000",
    "number": "1215066949",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 15099",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468855099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4402 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468156917",
            "telephone_number": "260-969-7846",
            "fax_number": "260-483-1734"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE MEDICAL ONCOLOGY & HEMAT",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-06",
        "last_updated": "2010-05-03",
        "status": "A",
        "authorized_official_last_name": "MARAVILLA",
        "authorized_official_first_name": "TRACY",
        "authorized_official_title_or_position": "PHARMACY DIRECTOR",
        "authorized_official_telephone_number": "260-484-9660",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "IN",
            "license": "60005894A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200544860A",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "1560247",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FT WAYNE MED ONCOLOGY AND HEMATOLOGY",
            "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 May 3, 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.