Provider Demographics
NPI:1376853994
Name:ENT & SLEEP MEDICINE ASSOCIATES LLC
Entity Type:Organization
Organization Name:ENT & SLEEP MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-628-0715
Mailing Address - Street 1:1000 ELEVEN S STE 4F
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1080
Mailing Address - Country:US
Mailing Address - Phone:618-628-0715
Mailing Address - Fax:888-371-4468
Practice Address - Street 1:1000 ELEVEN S STE 4F
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1080
Practice Address - Country:US
Practice Address - Phone:618-628-0715
Practice Address - Fax:888-371-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-16
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101869207Y00000X, 207YS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty