Basic Information
| Provider Information | |||||||||
| NPI: | 1689732836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMONWEALTH EAR NOSE & THROAT-HEAD & NECK CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 DUPONT CIRCLE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
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| Address1: | DEPARTMENT 8033 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601228033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | SELLERS | ||||||||
| AuthorizedOfficialFirstName: | HARRIET | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CERTIFIED CODING PROFESSIONAL | ||||||||
| AuthorizedOfficialTelephone: | 5028930159 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | CB7082 | 01 | RR MEDICARE PIN NUMBER | OTHER | 100011000A | 05 | IN | MEDICAID | 65912396 | 05 | KY | MEDICAID |