1912029596 NPI number — OTOLARYNGOLOGY ASSOCIATES LLC

Table of content: (NPI 1912029596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912029596 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:
1912029596
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:
2200 JOHN R WOODEN DR
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46151-1838
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: 100057100C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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