NPIMap

Organization Active NPI

Fort Wayne Medical Laboratory Corporation

  • Medical Laboratory Technician
  • Fort Wayne, IN
National Provider Identifier
1285610733
Registry record updated Mar 1, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Laboratory TechnicianTaxonomy code 246RM2200X
License
50000070A Issued in IN
Legal business name
FORT WAYNE MEDICAL LABORATORY CORPORATION
Practice address
2470 Lake Ave
Ft Wayne, IN 46805-5406
Phone
(260) 424-2195
NPI assigned
Dec 16, 2005
Last updated
Mar 1, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 1, 2012

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

Authorized official

Name
Seung S Kim, MD., PHDNPI 1639153182
Title
Laboratory Director
Phone
(260) 373-3657

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Laboratory Technician 246RM2200X 50000070A IN Primary

Addresses

Primary practice location

2470 Lake Ave
Ft Wayne, IN 46805-5406

Mailing address

2470 Lake Ave
Fort Wayne, IN 46805-5406
Phone (260) 424-2195

Other identifiers 1

IdentifierTypeStateIssuer
200402190AMedicaidIN

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041122000216 IN Part B Supplier - Independent Clinical Laboratory 7012972821 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
15D0358154Fort Wayne Medical Lab Corp2470 Lake Ave, Fort Wayne, IN 46805AccreditationJan 7, 2028

National Provider Directory

National Provider Directory

Locations

4250 Reliable Pkwy
Chicago, IL 60686

2470 Lake Ave
Fort Wayne, IN 46805
Phone (219) 482-3469

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1134691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1330560000000",
    "number": "1285610733",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2470 LAKE AVE",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468055406",
            "telephone_number": "260-424-2195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2470 LAKE AVE",
            "city": "FT WAYNE",
            "state": "IN",
            "postal_code": "468055406",
            "telephone_number": "260-424-2195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE MEDICAL LABORATORY CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-16",
        "last_updated": "2012-03-01",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "SEUNG",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "LABORATORY DIRECTOR",
        "authorized_official_telephone_number": "260-373-3657",
        "authorized_official_credential": "MD., PHD"
    },
    "taxonomies": [
        {
            "code": "246RM2200X",
            "taxonomy_group": "",
            "desc": "Technician, Pathology, Medical Laboratory",
            "state": "IN",
            "license": "50000070A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200402190A",
            "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 Mar 1, 2012; 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.