Provider Demographics
NPI:1326157140
Name:BURLINGTON EAR NOSE & THROAT CLINIC PC
Entity Type:Organization
Organization Name:BURLINGTON EAR NOSE & THROAT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HENRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-752-2725
Mailing Address - Street 1:1225 S GEAR AVE
Mailing Address - Street 2:STE 255
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1687
Mailing Address - Country:US
Mailing Address - Phone:319-752-2725
Mailing Address - Fax:319-753-1084
Practice Address - Street 1:1225 S GEAR AVE
Practice Address - Street 2:STE 255
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1687
Practice Address - Country:US
Practice Address - Phone:319-752-2725
Practice Address - Fax:319-753-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31549 / 34553207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06724OtherWELLMARK GROUP NUMBER
1326157140OtherMEDICARE GROUP NPI
IAI5597OtherMEDICARE ID