Provider Demographics
NPI:1952388837
Name:SUMMERLIN OTOLOGY INC
Entity Type:Organization
Organization Name:SUMMERLIN OTOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUMMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-923-5439
Mailing Address - Street 1:3351 N MERIDIAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4674
Mailing Address - Country:US
Mailing Address - Phone:317-923-5439
Mailing Address - Fax:317-923-4633
Practice Address - Street 1:3351 N MERIDIAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4674
Practice Address - Country:US
Practice Address - Phone:317-923-5439
Practice Address - Fax:317-923-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01017561207Y00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100119090AMedicaid
IN041068120OtherRAILROAD
IN200891910AMedicaid
IN100065670CMedicaid
IN959880Medicare PIN