Provider Demographics
NPI:1073700993
Name:OTOLARYNGOLOGY HEAD AND NECK SURGERY LLC
Entity Type:Organization
Organization Name:OTOLARYNGOLOGY HEAD AND NECK SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CUSUMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-251-9100
Mailing Address - Street 1:1 W RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2359
Mailing Address - Country:US
Mailing Address - Phone:201-251-9100
Mailing Address - Fax:
Practice Address - Street 1:1 W RIDGEWOOD AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:201-251-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50345207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065888Medicare PIN