Provider Demographics
NPI:1407948011
Name:WATERTOWN EAR NOSE AND THROAT GRP
Entity Type:Organization
Organization Name:WATERTOWN EAR NOSE AND THROAT GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAXTON
Authorized Official - Middle Name:L
Authorized Official - Last Name:HILLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-788-1751
Mailing Address - Street 1:826 WASHINGTON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4064
Mailing Address - Country:US
Mailing Address - Phone:315-788-1751
Mailing Address - Fax:315-788-9021
Practice Address - Street 1:826 WASHINGTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4064
Practice Address - Country:US
Practice Address - Phone:315-788-1751
Practice Address - Fax:315-788-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00458053Medicaid
NY00458053Medicaid