Provider Demographics
NPI:1497055099
Name:EAR CLINIC OF INDIANA LLC
Entity Type:Organization
Organization Name:EAR CLINIC OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-414-4882
Mailing Address - Street 1:9604 COLDWATER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2096
Mailing Address - Country:US
Mailing Address - Phone:260-387-5820
Mailing Address - Fax:
Practice Address - Street 1:9604 COLDWATER RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2096
Practice Address - Country:US
Practice Address - Phone:260-387-5820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044624174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201005050Medicaid
IN201005050Medicaid