Provider Demographics
NPI:1417903774
Name:NORTHEAST OTOLARYNGOLOGY, P.C.
Entity Type:Organization
Organization Name:NORTHEAST OTOLARYNGOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODINE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:STAEBLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:317-621-6673
Mailing Address - Street 1:18000 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8329
Mailing Address - Country:US
Mailing Address - Phone:317-621-6673
Mailing Address - Fax:317-621-3073
Practice Address - Street 1:18000 RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8329
Practice Address - Country:US
Practice Address - Phone:317-621-6673
Practice Address - Fax:317-621-3073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN313100Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #