Basic Information
| Provider Information | |||||||||
| NPI: | 1124217765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENTLC, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 491 TUCKER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067594852 | ||||||||
| FaxNumber: | 6067590112 | ||||||||
| Practice Location | |||||||||
| Address1: | 491 TUCKER DR | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067594852 | ||||||||
| FaxNumber: | 6067590112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | CONRAD | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6067594852 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D., F.A.C.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 0478 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | 0946 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 363LF0000X | 6223P | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Y00000X | 35183 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.