Contract Details
Ancillary Care Services
Facility name
Source One Medical
Provider ID
P000004957
NPI
1619972239
Tax ID
330830765
Effective Date
4/1/2012
Last Updated
10/21/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
2208 Contractors Drive Suite K-19
Fort Wayne, IN 46818
United States
County
Allen
Phone
9252000105 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Durable Medical Equipment & Medical Supplies
Map
Address