1679835086 NPI number — EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC

Table of content: (NPI 1679835086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679835086 NPI number — EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC
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:
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:
1679835086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06473-2304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-234-1324
Provider Business Mailing Address Fax Number:
203-239-3047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 PRINCE ST STE 601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-752-1726
Provider Business Practice Location Address Fax Number:
203-752-1838
Provider Enumeration Date:
06/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CZIBULKA
Authorized Official First Name:
AGNES
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN PARTNER
Authorized Official Telephone Number:
203-234-1324

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  004907 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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