Basic Information
| Provider Information | |||||||||
| NPI: | 1467502534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EWING-EAR, NOSE & THROAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 GREENBRIAR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 2707892044 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 GREENBRIAR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 2707892044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | EWING | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2704653595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 29697 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 65931966 | 05 | KY | MEDICAID | 000000054088 | 01 | KY | ANTHEM BLUE CROSS GROUP | OTHER |