Provider Demographics
NPI:1508960774
Name:ORL PC
Entity Type:Organization
Organization Name:ORL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:C
Authorized Official - Last Name:SNYDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-422-2386
Mailing Address - Street 1:800 BROADWAY
Mailing Address - Street 2:STE 207
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2149
Mailing Address - Country:US
Mailing Address - Phone:260-422-2386
Mailing Address - Fax:260-422-3985
Practice Address - Street 1:800 BROADWAY
Practice Address - Street 2:STE 207
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2149
Practice Address - Country:US
Practice Address - Phone:260-422-2386
Practice Address - Fax:260-422-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01016604A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000085958OtherANTHEM BCBS
IN133350Medicare ID - Type Unspecified
B28466Medicare UPIN