Provider Demographics
NPI:1720157951
Name:LAFAYETTE OTOLARYNGOLOGY ASSOCIATES, INC
Entity Type:Organization
Organization Name:LAFAYETTE OTOLARYNGOLOGY ASSOCIATES, INC
Other - Org Name:LAFAYETTE ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-477-7436
Mailing Address - Street 1:2320 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-2708
Mailing Address - Country:US
Mailing Address - Phone:765-477-7436
Mailing Address - Fax:765-477-1245
Practice Address - Street 1:2320 CONCORD RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-2708
Practice Address - Country:US
Practice Address - Phone:765-477-7436
Practice Address - Fax:765-477-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200274580AMedicaid
IN215170Medicare ID - Type Unspecified