Provider Demographics
NPI:1083656672
Name:NORTHSIDE ENT, INC
Entity Type:Organization
Organization Name:NORTHSIDE ENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DARVINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-818-5447
Mailing Address - Street 1:12065 OLD MERIDIAN STREET
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8772
Mailing Address - Country:US
Mailing Address - Phone:317-844-5656
Mailing Address - Fax:317-575-3797
Practice Address - Street 1:12065 OLD MERIDIAN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8773
Practice Address - Country:US
Practice Address - Phone:317-844-5656
Practice Address - Fax:317-575-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002085A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100062900AMedicaid
IN079890Medicare PIN