1720157951 NPI number — LAFAYETTE OTOLARYNGOLOGY ASSOCIATES, INC

Table of content: KRISTEN RESNICK MEDICAL ASSISTANT (NPI 1790924504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720157951 NPI number — LAFAYETTE OTOLARYNGOLOGY ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAFAYETTE OTOLARYNGOLOGY ASSOCIATES, 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:
6
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:
1720157951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2320 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47909-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-477-7436
Provider Business Mailing Address Fax Number:
765-477-1245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2320 CONCORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47909-2708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-477-7436
Provider Business Practice Location Address Fax Number:
765-477-1245
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RODEHAN
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
765-477-7436

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: 200274580A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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