Provider Demographics
NPI:1033271820
Name:REGIONAL EAR NOSE AND THROAT ASSOCIATES
Entity Type:Organization
Organization Name:REGIONAL EAR NOSE AND THROAT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-778-0559
Mailing Address - Street 1:204 ARK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 ARK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3100
Practice Address - Country:US
Practice Address - Phone:856-778-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3540405Medicaid
527525Medicare ID - Type UnspecifiedGROUP MEDICARE