1073635553 NPI number — OTOLARYNGOLOGY ASSOCIATES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073635553 NPI number — OTOLARYNGOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTOLARYNGOLOGY ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073635553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9002 N MERIDIAN ST
Provider Second Line Business Mailing Address:
STE 222
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-5350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-573-4370
Provider Business Mailing Address Fax Number:
317-819-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18051 RIVER AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
NOBLESVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46062-7093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-844-7059
Provider Business Practice Location Address Fax Number:
317-573-4352
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FAIRCHILD
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-844-7059

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200838770F , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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