Provider Demographics
NPI:1295726198
Name:EAR, NOSE AND THROAT OF MICHIANA P.C.
Entity type:Organization
Organization Name:EAR, NOSE AND THROAT OF MICHIANA P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-246-1000
Mailing Address - Street 1:209 FLORENCE AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8048
Mailing Address - Country:US
Mailing Address - Phone:574-246-1000
Mailing Address - Fax:574-246-4000
Practice Address - Street 1:209 FLORENCE AVENUE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8048
Practice Address - Country:US
Practice Address - Phone:574-246-1000
Practice Address - Fax:574-246-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035158A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200485700AMedicaid
IN200717560AOtherFIRST STEPS-IN
IN233610Medicare PIN
IN200485700AMedicaid
IN200485700AMedicaid