Healthcare Provider Details

I. General information

NPI: 1508960774
Provider Name (Legal Business Name): ORL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BROADWAY STE 207
FORT WAYNE IN
46802-2149
US

IV. Provider business mailing address

800 BROADWAY STE 207
FORT WAYNE IN
46802-2149
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-2386
  • Fax: 260-422-3985
Mailing address:
  • Phone: 260-422-2386
  • Fax: 260-422-3985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01016604A
License Number StateIN

VIII. Authorized Official

Name: SANFORD C SNYDERMAN
Title or Position: SECRETARY
Credential: MD
Phone: 260-422-2386