Provider Demographics
NPI:1154488732
Name:EAR,NOSE,THROAT & ALLERGY ASSOCIATES PS
Entity Type:Organization
Organization Name:EAR,NOSE,THROAT & ALLERGY ASSOCIATES PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-770-8454
Mailing Address - Street 1:104 27TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-1145
Mailing Address - Country:US
Mailing Address - Phone:253-770-9000
Mailing Address - Fax:
Practice Address - Street 1:104 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1145
Practice Address - Country:US
Practice Address - Phone:253-770-8454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7078017Medicaid
WAAB01419Medicare PIN