Basic Information
| Provider Information | |||||||||
| NPI: | 1790854651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR NOSE AND THROAT MEDICAL & 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: | 31 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064732304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032341324 | ||||||||
| FaxNumber: | 2032393047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALBERTI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2032341324 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/31/2022 | ||||||||
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 | 004396140 | 05 | CT | MEDICAID |