Healthcare Provider Details

I. General information

NPI: 1851377691
Provider Name (Legal Business Name): EAR, NOSE & THROAT ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10021 DUPONT CIRCLE CT
FORT WAYNE IN
46825-1604
US

IV. Provider business mailing address

10021 DUPONT CIRCLE CT
FORT WAYNE IN
46825-1604
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-8117
  • Fax: 260-420-0817
Mailing address:
  • Phone: 260-426-8117
  • Fax: 260-420-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number50000001A
License Number StateIN

VIII. Authorized Official

Name: BRIAN D. HERR
Title or Position: PARTNER/PRESIDENT
Credential: MD
Phone: 260-426-8117