1083656672 NPI number — NORTHSIDE ENT, INC

Table of content: (NPI 1083656672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083656672 NPI number — NORTHSIDE ENT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE ENT, INC
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:
1083656672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12065 OLD MERIDIAN STREET
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-8772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-844-5656
Provider Business Mailing Address Fax Number:
317-575-3797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12065 OLD MERIDIAN ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-8773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-844-5656
Provider Business Practice Location Address Fax Number:
317-575-3795
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GALLON
Authorized Official First Name:
DARVINA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
317-818-5447

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  23002085A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100062900A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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