1609019363 NPI number — OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A.

Table of content: (NPI 1609019363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609019363 NPI number — OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A.
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:
1609019363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 RADIO DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-702-0750
Provider Business Mailing Address Fax Number:
651-645-6166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 RADIO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-702-0750
Provider Business Practice Location Address Fax Number:
651-645-6166
Provider Enumeration Date:
04/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BENUSA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
651-702-0750

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  20 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1821195959 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821195959 . This is a "MEDICARE PTAN C00273" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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