1942246822 NPI number — OTORHINOLARYNGOLOGY, INC

Table of content: (NPI 1942246822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942246822 NPI number — OTORHINOLARYNGOLOGY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTORHINOLARYNGOLOGY, 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:
1942246822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1916
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46634-1916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-232-4800
Provider Business Mailing Address Fax Number:
574-282-1018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 MEMORIAL DR
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-232-4800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLETZING
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-232-4800

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 207Y00000X . This is a "OTO TAXONOMY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 207YX0602Y . This is a "ALLERGY TAXONOMY 1" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35157729 . This is a "TAX IDENTIFICATION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100465500 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207YX0905X . This is a "FACIAL PLASTIC TAXONOMY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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