Provider Demographics
NPI:1942246822
Name:OTORHINOLARYNGOLOGY, INC
Entity Type:Organization
Organization Name:OTORHINOLARYNGOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:KLETZING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-232-4800
Mailing Address - Street 1:PO BOX 1916
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-1916
Mailing Address - Country:US
Mailing Address - Phone:574-232-4800
Mailing Address - Fax:574-282-1018
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:SUITE 402
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-232-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN207Y00000XOtherOTO TAXONOMY
IN207YX0602YOtherALLERGY TAXONOMY 1
IN35157729OtherTAX IDENTIFICATION
IN100465500Medicaid
IN207YX0905XOtherFACIAL PLASTIC TAXONOMY
IN100465500Medicaid