Provider Demographics
NPI:1225684368
Name:FORT WAYNE VASCULAR CARE LLC
Entity type:Organization
Organization Name:FORT WAYNE VASCULAR CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-573-5000
Mailing Address - Street 1:120 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1557
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-368-0280
Practice Address - Street 1:1833 MAGNAVOX WAY # 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1539
Practice Address - Country:US
Practice Address - Phone:260-918-0997
Practice Address - Fax:260-436-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty