MEDICARE: ORL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	01016604A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000085958	OTHER	IN	ANTHEM BCBS

General Provider Information

NPI Number	:	1508960774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORL PC

Provider Business Mailing Address
First Line	:	800 BROADWAY
Second Line	:	STE 207
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-2149
Country	:	US
Telephone Number	:	260-422-2386
Fax Number	:	260-422-3985

Provider Business Practice Location Address
First Line	:	800 BROADWAY
Second Line	:	STE 207
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-2149
Country	:	US
Telephone Number	:	260-422-2386
Fax Number	:	260-422-3985

Authorized Official
Title or Position	:	SECRETARY
Name	:	SANFORD C SNYDERMAN
Credential	:	MD
Telephone Number	:	260-422-2386

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	08/22/2020

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Directions to “ORL PC ” Practice Location

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