Provider Demographics
NPI:1043419823
Name:BEDFORD EAR NOSE & THROAT CLINIC INC
Entity type:Organization
Organization Name:BEDFORD EAR NOSE & THROAT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASOON
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:SAMADDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-279-4304
Mailing Address - Street 1:PO BOX 1178
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-1178
Mailing Address - Country:US
Mailing Address - Phone:812-279-4304
Mailing Address - Fax:812-275-8441
Practice Address - Street 1:1706 24TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4708
Practice Address - Country:US
Practice Address - Phone:812-279-4304
Practice Address - Fax:812-275-8441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026176A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1184706228Medicaid
IN212010AMedicare PIN
INB29070Medicare UPIN