MEDICARE: OTOLARYNGOLOGY ASSOCIATES LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912029596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTOLARYNGOLOGY ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	9002 N MERIDIAN ST
Second Line	:	STE 222
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-5350
Country	:	US
Telephone Number	:	317-573-4370
Fax Number	:	317-819-0044

Provider Business Practice Location Address
First Line	:	2200 JOHN R WOODEN DR
Second Line	:	STE 205
City	:	MARTINSVILLE
State	:	IN
Zip	:	46151-1838
Country	:	US
Telephone Number	:	317-844-7059
Fax Number	:	317-573-4352

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS H FAIRCHILD
Credential	:	M.D.
Telephone Number	:	317-844-7059

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/20/2010

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