Provider Demographics
NPI:1003807330
Name:ENT PROFESSIONAL ASSOCIATES SC
Entity Type:Organization
Organization Name:ENT PROFESSIONAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-682-9311
Mailing Address - Street 1:1625 MAPLE LN
Mailing Address - Street 2:STE 2
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3768
Mailing Address - Country:US
Mailing Address - Phone:715-682-9311
Mailing Address - Fax:715-682-2486
Practice Address - Street 1:1625 MAPLE LN
Practice Address - Street 2:STE 2
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3768
Practice Address - Country:US
Practice Address - Phone:715-682-9311
Practice Address - Fax:715-682-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32666100Medicaid
WI04041Medicare ID - Type Unspecified
WI04041Medicare PIN
WI32666100Medicaid