Provider Demographics
NPI:1164480240
Name:PENSACOLA EAR NOSE AND THROAT PL
Entity Type:Organization
Organization Name:PENSACOLA EAR NOSE AND THROAT PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:850-532-3467
Mailing Address - Street 1:1717 NORTH E STREET
Mailing Address - Street 2:STE 239
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501
Mailing Address - Country:US
Mailing Address - Phone:850-432-3467
Mailing Address - Fax:850-434-2308
Practice Address - Street 1:1717 NORTH E STREET
Practice Address - Street 2:STE 239
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501
Practice Address - Country:US
Practice Address - Phone:850-432-3467
Practice Address - Fax:850-434-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39522OtherBLUE CROSS BLUE SHIELD
FL276479200Medicaid
FL39522OtherBLUE CROSS BLUE SHIELD