Basic Information
| Provider Information | |||||||||
| NPI: | 1568492858 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR, NOSE, AND THROAT ASSOCIATES OF NORTHWESTERN PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 545 | ||||||||
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| City: | SENECA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163460545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146776381 | ||||||||
| FaxNumber: | 8146776384 | ||||||||
| Practice Location | |||||||||
| Address1: | TWO PARK WAY | ||||||||
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| City: | SENECA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146776381 | ||||||||
| FaxNumber: | 8146776384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASLOV | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8146776381 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD045086E | PA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 291U00000X | 025111 | PA | X | Laboratories | Clinical Medical Laboratory | 231H00000X | AT000043L | PA | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | AT000767L | PA | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | AT001170L | PA | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 100742736 0009 | 05 | PA | MEDICAID | 100742736 0002 | 05 | PA | MEDICAID | 725508 | 01 | PA | HIGHMARK GROUP # | OTHER | 997088 | 01 | PA | HIGHMARK GROUP AUDIOLOGY | OTHER |