Provider Demographics
NPI:1093936395
Name:EAR, NOSE & THROAT INSTITUTE OF SOUTHERN ILLINOIS LTD.
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT INSTITUTE OF SOUTHERN ILLINOIS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:618-235-3687
Mailing Address - Street 1:19 WOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2355
Mailing Address - Country:US
Mailing Address - Phone:618-235-3687
Mailing Address - Fax:618-239-9492
Practice Address - Street 1:4325 EE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-3445
Practice Address - Country:US
Practice Address - Phone:618-235-3687
Practice Address - Fax:618-239-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL975340Medicare ID - Type UnspecifiedCORP MEDICARE NUMBER