Provider Demographics
NPI:1154445930
Name:EAR NOSE THROAT & SPECIALIST-CHEROKEE SINUS CENTER
Entity Type:Organization
Organization Name:EAR NOSE THROAT & SPECIALIST-CHEROKEE SINUS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN TUYL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-345-6600
Mailing Address - Street 1:215 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-345-6600
Mailing Address - Fax:770-345-6611
Practice Address - Street 1:215 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-345-6600
Practice Address - Fax:770-345-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000509187QMedicaid
GAE91154Medicare UPIN
GA000509187QMedicaid
GA04BDCJCMedicare ID - Type Unspecified