=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508960774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 BROADWAY STE 207
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46802-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-422-2386
-----------------------------------------------------
Fax | 260-422-3985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 BROADWAY STE 207
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46802-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-422-2386
-----------------------------------------------------
Fax | 260-422-3985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | SANFORD C SNYDERMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 260-422-2386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 01016604A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------