Healthcare Provider Details

I. General information

NPI: 1083656672
Provider Name (Legal Business Name): NORTHSIDE ENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12065 OLD MERIDIAN ST SUITE 205
CARMEL IN
46032-8773
US

IV. Provider business mailing address

12065 OLD MERIDIAN STREET SUITE 205
CARMEL IN
46032-8772
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-5656
  • Fax: 317-575-3795
Mailing address:
  • Phone: 317-844-5656
  • Fax: 317-575-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002085A
License Number StateIN

VIII. Authorized Official

Name: DARVINA L GALLON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 317-818-5447