Provider Demographics
NPI:1356682033
Name:ENT SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ENT SURGERY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JAMOULIS
Authorized Official - Last Name:JAMESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-499-9933
Mailing Address - Street 1:725 CONCORD AVE
Mailing Address - Street 2:2300
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1040
Mailing Address - Country:US
Mailing Address - Phone:617-499-9933
Mailing Address - Fax:617-499-9935
Practice Address - Street 1:725 CONCORD AVE
Practice Address - Street 2:2300
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1040
Practice Address - Country:US
Practice Address - Phone:617-499-9933
Practice Address - Fax:617-499-9935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72421207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110049047Medicaid
MA110049047Medicaid