Provider Demographics
NPI:1396199881
Name:CITY LINE E.N.T., PC
Entity Type:Organization
Organization Name:CITY LINE E.N.T., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-879-0060
Mailing Address - Street 1:4190 CITY AVE
Mailing Address - Street 2:STE 526
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-879-0060
Mailing Address - Fax:215-879-0063
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:STE 526
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-879-0060
Practice Address - Fax:215-879-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0011941L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty