Provider Demographics
NPI:1073660866
Name:NORTH CENTRAL INDIANA EAR NOSE AND THROAT, PC
Entity Type:Organization
Organization Name:NORTH CENTRAL INDIANA EAR NOSE AND THROAT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-753-2222
Mailing Address - Street 1:800 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1577
Mailing Address - Country:US
Mailing Address - Phone:574-753-2222
Mailing Address - Fax:574-753-0522
Practice Address - Street 1:800 FULTON ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1577
Practice Address - Country:US
Practice Address - Phone:574-753-2222
Practice Address - Fax:574-753-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1134184153OtherNPI
IN1134184153OtherNPI
IN112840Medicare ID - Type Unspecified