Healthcare Provider Details

I. General information

NPI: 1952388837
Provider Name (Legal Business Name): SUMMERLIN OTOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 N MERIDIAN ST SUITE 100
INDIANAPOLIS IN
46208-4674
US

IV. Provider business mailing address

3351 N MERIDIAN ST SUITE 100
INDIANAPOLIS IN
46208-4674
US

V. Phone/Fax

Practice location:
  • Phone: 317-923-5439
  • Fax: 317-923-4633
Mailing address:
  • Phone: 317-923-5439
  • Fax: 317-923-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01017561
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK D SUMMERLIN
Title or Position: PRESIDENT MD
Credential: MD
Phone: 317-923-5439