Basic Information
| Provider Information | |||||||||
| NPI: | 1073655882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED EAR NOSE AND THROAT ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | LADD | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4049430900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 657566 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | CH9705 | 01 | GA | RAILROAD MEDICARE | OTHER |