1841490067 NPI number — ENT SPECIALTY CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841490067 NPI number — ENT SPECIALTY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENT SPECIALTY CARE
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:
1841490067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2004 ROUTE 17M
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10924-5210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-294-0661
Provider Business Mailing Address Fax Number:
845-818-9646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MATTHEWS ST #105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10924-1985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-294-0661
Provider Business Practice Location Address Fax Number:
845-818-9646
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
845-294-0661

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  183723 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CR54 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: LA0WWT4710 . This is a "EMPIRE NEW YORK BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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