Basic Information
| Provider Information | |||||||||
| NPI: | 1316167463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR NOSE AND THROAT SPECIALISTS OF WEST CENTRAL OHIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 WEST HIGH ST | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192279500 | ||||||||
| FaxNumber: | 4192279503 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 WEST HIGH ST | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192279500 | ||||||||
| FaxNumber: | 4192279503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DALTON | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | ELLIOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4192279500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35083245 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 35083245 | 01 | OH | LICENSE NUMBER | OTHER | AD9452448 | 01 | DEA NUMBER | OTHER | 2445705 | 05 | OH | MEDICAID |