Provider Demographics
NPI:1265651947
Name:PREMIER EAR, NOSE AND THROAT SURGEONS, LTD
Entity Type:Organization
Organization Name:PREMIER EAR, NOSE AND THROAT SURGEONS, LTD
Other - Org Name:VALLEY EAR, NOSE AND THROAT SURGEONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-678-5001
Mailing Address - Street 1:9250 N 3RD ST
Mailing Address - Street 2:STE. 3025
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2412
Mailing Address - Country:US
Mailing Address - Phone:602-678-5001
Mailing Address - Fax:602-678-4787
Practice Address - Street 1:9250 N 3RD ST
Practice Address - Street 2:STE. 3025
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2412
Practice Address - Country:US
Practice Address - Phone:602-678-5001
Practice Address - Fax:602-678-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ755879Medicaid
AZ364935Medicaid
AZ364935Medicaid
AZZ116968Medicare PIN
AZ755879Medicaid