1790019784 NPI number — EAR NOSE AND THROAT ASSOCIATES OF LUBBOCK PA

Table of content: JENNA KELEMEN APRN (NPI 1457151383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790019784 NPI number — EAR NOSE AND THROAT ASSOCIATES OF LUBBOCK PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE AND THROAT ASSOCIATES OF LUBBOCK PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790019784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3802 22ND ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-791-0188
Provider Business Mailing Address Fax Number:
806-788-0470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3802 22ND ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-791-0188
Provider Business Practice Location Address Fax Number:
806-788-0470
Provider Enumeration Date:
09/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SCOLARO
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
806-791-0188

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8CD477 . This is a "GROUP BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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