Provider Demographics
NPI:1326076316
Name:PHILADELPHIA EAR, NOSE & THROAT SURGICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:PHILADELPHIA EAR, NOSE & THROAT SURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSELLEN
Authorized Official - Middle Name:MEEHAN
Authorized Official - Last Name:TOMCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-423-6670
Mailing Address - Street 1:2340 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4433
Mailing Address - Country:US
Mailing Address - Phone:215-423-6670
Mailing Address - Fax:215-423-7787
Practice Address - Street 1:2340 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19134-4433
Practice Address - Country:US
Practice Address - Phone:215-423-6670
Practice Address - Fax:215-423-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017012E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA48078Medicare UPIN
PA103880Medicare PIN