Healthcare Provider Details

I. General information

NPI: 1477182988
Provider Name (Legal Business Name): ALLERGY AND AUDIOLOGY SERVICES OF NORTHWEST INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RIDGE RD STE E
MUNSTER IN
46321-1727
US

IV. Provider business mailing address

900 RIDGE RD STE E
MUNSTER IN
46321-1727
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LYNN MCDONALD
Title or Position: CREDENTIALING
Credential:
Phone: 219-769-1670