Basic Information
| Provider Information | |||||||||
| NPI: | 1265865232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR, NOSE, THROAT, AND ALLERGY SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80A INTERSTATE SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301436226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703456600 | ||||||||
| FaxNumber: | 7703456611 | ||||||||
| Practice Location | |||||||||
| Address1: | 80A INTERSTATE SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301436226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703456600 | ||||||||
| FaxNumber: | 7703456611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | VAN TUYL | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7703456600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAR, NOSE, THROAT, AND ALLERGY SPECIALISTS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 30684 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.