Provider Demographics
NPI:1073655882
Name:ADVANCED EAR NOSE AND THROAT ASSOCIATES PC
Entity Type:Organization
Organization Name:ADVANCED EAR NOSE AND THROAT ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-943-0900
Mailing Address - Street 1:960 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-943-0900
Mailing Address - Fax:404-943-1390
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-943-0900
Practice Address - Fax:404-943-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA657566207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH9705OtherRAILROAD MEDICARE
GACH9705OtherRAILROAD MEDICARE