Provider Demographics
NPI:1295141380
Name:GYNECOLOGIC ONCOLOGY OF NORTHEAST INDIANA, LLC
Entity type:Organization
Organization Name:GYNECOLOGIC ONCOLOGY OF NORTHEAST INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IWONA
Authorized Official - Middle Name:
Authorized Official - Last Name:PODZIELINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-437-4789
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-0307
Mailing Address - Country:US
Mailing Address - Phone:260-437-4789
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-437-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201236690Medicaid
OH0107737Medicaid
ININ2037Medicare PIN