MEDICARE: EAR, NOSE & THROAT ASSOCIATES, 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	50000001A	IN

General Provider Information

NPI Number	:	1619954468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAR, NOSE & THROAT ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	10021 DUPONT CIRCLE CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1604
Country	:	US
Telephone Number	:	260-426-8117
Fax Number	:	260-420-0817

Provider Business Practice Location Address
First Line	:	1169 N MAIN ST
Second Line	:	SUITE 5
City	:	BLUFFTON
State	:	IN
Zip	:	46714-1360
Country	:	US
Telephone Number	:	260-827-4368
Fax Number	:	260-827-4370

Authorized Official
Title or Position	:	CEO
Name	:	KENN VAN DER WEELE
Credential	:
Telephone Number	:	260-207-1675

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	08/22/2020

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