Basic Information
| Provider Information | |||||||||
| NPI: | 1366572158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAR NOSE AND THROAT ASSOCIATES OF GRANTS PASS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 NW 6TH ST | ||||||||
| Address2: | SOUTH SUITE | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414767775 | ||||||||
| FaxNumber: | 5414763572 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 NW 6TH ST | ||||||||
| Address2: | SOUTH SUITE | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414767775 | ||||||||
| FaxNumber: | 5414763572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | REECE | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5414767775 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | MD19356 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207YX0905X | DO20532 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207YX0905X | MD10466 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 232900 | 05 | OR | MEDICAID | 073655 | 05 | OR | MEDICAID | 150358 | 05 | OR | MEDICAID |