Healthcare Provider Details

I. General information

NPI: 1023130333
Provider Name (Legal Business Name): OTOLARYNGOLOGY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 RONALD REAGAN PKWY STE 255
AVON IN
46123-6913
US

IV. Provider business mailing address

9002 N MERIDIAN ST STE 222
INDIANAPOLIS IN
46260-5350
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-7059
  • Fax: 317-573-4352
Mailing address:
  • Phone: 317-573-4370
  • Fax: 317-819-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS H FAIRCHILD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 317-844-7059