Provider Demographics
NPI:1104007111
Name:SOUTHERN ILLINOIS OTOLARYNGOLOGY, LTD
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS OTOLARYNGOLOGY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:DOBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-235-8082
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 930
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-235-8082
Mailing Address - Fax:618-235-7795
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 930
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-235-8082
Practice Address - Fax:618-235-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL647890OtherMEDICARE PTAN
ILD14296Medicare UPIN