NPIMap

Organization Active NPI

Great Lakes Pediatric Surgeons, Inc.

  • Pediatric Surgery Physician
  • Fort Wayne, IN
National Provider Identifier
1669455267
Registry record updated Mar 14, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Surgery PhysicianTaxonomy code 2086S0120X
Legal business name
GREAT LAKES PEDIATRIC SURGEONS, INC.
Practice address
7613 W Jefferson Blvd Ste 200
Fort Wayne, IN 46804-4182
Phone
(260) 469-7337
Fax
(260) 469-7340
NPI assigned
Nov 29, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2008

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

Authorized official

Name
David A. Smith, M.D.NPI 1962405993
Title
President
Phone
(260) 469-7337

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
Pediatric Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2086S0120X Primary

Addresses

Primary practice location

7613 W Jefferson Blvd Ste 200
Fort Wayne, IN 46804-4182

Mailing address

7613 W Jefferson Blvd Ste 200
Fort Wayne, IN 46804-4182
Phone (260) 469-7337

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041108000793 IN Part B Supplier - Clinic/Group Practice 1052374337 Receives reassigned benefits from 7 practitioners
Practice locations: Fort Wayne, IN

National Provider Directory

National Provider Directory

Locations

7613 W Jefferson Blvd
Fort Wayne, IN 46804
Phone (260) 469-7337

6211B Constitution Dr
Fort Wayne, IN 46804
Phone (260) 469-7337

7613 W Jefferson Blvd
Ste 200
Fort Wayne, IN 46804
Phone (260) 469-7337

Practitioners & affiliated clinicians

Practitioners 8

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

NPI Registry JSON

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

{
    "created_epoch": "1133222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1205452800000",
    "number": "1669455267",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7613 W JEFFERSON BLVD STE 200",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468044182",
            "telephone_number": "260-469-7337",
            "fax_number": "260-469-7340"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7613 W JEFFERSON BLVD STE 200",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468044182",
            "telephone_number": "260-469-7337",
            "fax_number": "260-469-7340"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES PEDIATRIC SURGEONS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-29",
        "last_updated": "2008-03-14",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "260-469-7337",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2086S0120X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery, Pediatric Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 14, 2008; 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.