NPIMap

Organization Active NPI

Fort Wayne Medical Oncology and Hematology, Inc

  • Hematology & Oncology Physician
  • Fort Wayne, IN
National Provider Identifier
1376533158
Registry record updated Dec 4, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Hematology & Oncology PhysicianTaxonomy code 207RH0003X
Legal business name
FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC
Practice address
2514 E Dupont Rd Ste 100
Fort Wayne, IN 46825-1619
Phone
(260) 484-8830
Fax
(260) 483-1911
NPI assigned
Oct 24, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 4, 2023

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

Authorized official

Name
Bethany Gisslen
Title
Cfo
Phone
(260) 484-8830

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Hematology & Oncology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RH0003X Primary

Addresses

Primary practice location

2514 E Dupont Rd Ste 100
Fort Wayne, IN 46825-1619

Mailing address

6610 Mutual Dr
Fort Wayne, IN 46825-4236
Phone (260) 484-8830

Other identifiers 2

IdentifierTypeStateIssuer
CA4536OtherINMEDICARE RR
100053330AMedicaidIN

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040329000797 IN Part B Supplier - Clinic/Group Practice 2961394440 Receives reassigned benefits from 28 practitioners
Practice locations: Peru, IN; Warsaw, IN; Wabash, IN; Marion, IN; Kendallville, IN; Fort Wayne, IN; Decatur, IN; Bluffton, IN…

National Provider Directory

National Provider Directory

Locations

7910 W Jefferson Blvd
Ste 108
Fort Wayne, IN 46804
Phone (219) 484-8830

6610 Mutual Dr
#4536
Fort Wayne, IN 46825

7910 W Jefferson Blvd
#4536
Fort Wayne, IN 46804

6610 Mutual Dr
Fort Wayne, IN 46825

2120 N Detroit St
Ste 101
Lagrange, IN 46761

1700 Alber St
Ste 106
Wabash, IN 46992

737 N Detroit St
Ste 108
Warsaw, IN 46580
Phone (888) 881-4368

208 Columbus St
Ste 4
Hicksville, OH 43526

Practitioners & affiliated clinicians

Practitioners 29

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

View all 29

NPI Registry JSON

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

{
    "created_epoch": "1130112000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701648000000",
    "number": "1376533158",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6610 MUTUAL DR",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468254236",
            "telephone_number": "260-484-8830",
            "fax_number": "260-483-1911"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2514 E DUPONT RD STE 100",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468251619",
            "telephone_number": "260-484-8830",
            "fax_number": "260-483-1911"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE MEDICAL ONCOLOGY AND HEMATOLOGY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-24",
        "last_updated": "2023-12-04",
        "certification_date": "2023-12-04",
        "status": "A",
        "authorized_official_last_name": "GISSLEN",
        "authorized_official_first_name": "BETHANY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "260-484-8830"
    },
    "taxonomies": [
        {
            "code": "207RH0003X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RR",
            "identifier": "CA4536",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100053330A",
            "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 Dec 4, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.