1649629957 NPI number — EAR NOSE AND THROAT CONSULTANTS

Table of content: (NPI 1649629957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649629957 NPI number — EAR NOSE AND THROAT CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE AND THROAT CONSULTANTS
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:
1649629957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 TOWER ROAD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
DAKOTA DUNES
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-217-4320
Provider Business Mailing Address Fax Number:
605-217-2948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 TOWER ROAD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
DAKOTA DUNES
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-217-4320
Provider Business Practice Location Address Fax Number:
605-217-2948
Provider Enumeration Date:
06/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JERDEE
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
605-217-4320

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  1919 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1919 . This is a "SOUTH DAKOTA LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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