Basic Information
| Provider Information | |||||||||
| NPI: | 1932136884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAND EAR NOSE & THROAT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2521 GLENN HENDREN DRIVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167811001 | ||||||||
| FaxNumber: | 8167920408 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DRIVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167811001 | ||||||||
| FaxNumber: | 8167920408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BEUERLEIN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8167811001 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 27835011 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | NENT627212 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |