Basic Information
Provider Information | |||||||||
NPI: | 1689782427 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED EAR NOSE & THROAT SPECIALISTS, SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | WAUWATOSA | ||||||||
State: | WI | ||||||||
PostalCode: | 532264851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889383838 | ||||||||
FaxNumber: | 8889191083 | ||||||||
Practice Location | |||||||||
Address1: | 2885 N MAYFAIR RD | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532224404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888893838 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 10/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KANDULA | ||||||||
AuthorizedOfficialFirstName: | MADAN | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8889383838 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 434 156 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   | 207YX0007X | 44930 020 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
ID | Type | State | Issuer | Description | 34336200 | 05 | WI |   | MEDICAID |