Provider Demographics
NPI:1033202718
Name:EAR, HEAD & NECK SPECIALISTS
Entity Type:Organization
Organization Name:EAR, HEAD & NECK SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-921-7770
Mailing Address - Street 1:253 DUNN ROAD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031
Mailing Address - Country:US
Mailing Address - Phone:314-921-7770
Mailing Address - Fax:314-921-1417
Practice Address - Street 1:253 DUNN ROAD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031
Practice Address - Country:US
Practice Address - Phone:314-921-7770
Practice Address - Fax:314-921-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502854300Medicaid
MO502854300Medicaid