1720208820 NPI number — EAR NOSE & THROAT MEDICINE & SURGERY OF PORTSMOUTH PA

Table of content: (NPI 1720208820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720208820 NPI number — EAR NOSE & THROAT MEDICINE & SURGERY OF PORTSMOUTH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR NOSE & THROAT MEDICINE & SURGERY OF PORTSMOUTH 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:
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:
1720208820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BORTHWICK AVE
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801-7109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-431-3477
Provider Business Mailing Address Fax Number:
603-430-9663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BORTHWICK AVE
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-7109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-431-3477
Provider Business Practice Location Address Fax Number:
603-430-9663
Provider Enumeration Date:
04/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YEGANEH
Authorized Official First Name:
EDMOND
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER/OFFICER
Authorized Official Telephone Number:
603-431-3477

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  NH5840 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30010589 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".