Basic Information
| Provider Information | |||||||||
| NPI: | 1679835086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064732304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032341324 | ||||||||
| FaxNumber: | 2032393047 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 PRINCE ST STE 601 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037521726 | ||||||||
| FaxNumber: | 2037521838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 07/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | CZIBULKA | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2032341324 | ||||||||
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| 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 | 363L00000X | 004907 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.