Provider Demographics
NPI:1386819704
Name:MID-COLUMBIA EAR, NOSE & THROAT, P.L.L.C.
Entity Type:Organization
Organization Name:MID-COLUMBIA EAR, NOSE & THROAT, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-585-0795
Mailing Address - Street 1:3903 S IRBY ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-2451
Mailing Address - Country:US
Mailing Address - Phone:509-585-0795
Mailing Address - Fax:
Practice Address - Street 1:3903 S IRBY ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-2451
Practice Address - Country:US
Practice Address - Phone:509-585-0795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-26
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032458207Y00000X
WALD0002175231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty