Provider Demographics
NPI:1417958786
Name:THOMASTON EAR, NOSE AND THROAT INC.
Entity Type:Organization
Organization Name:THOMASTON EAR, NOSE AND THROAT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-646-4508
Mailing Address - Street 1:210 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3402
Mailing Address - Country:US
Mailing Address - Phone:706-646-4508
Mailing Address - Fax:706-646-2752
Practice Address - Street 1:210 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3402
Practice Address - Country:US
Practice Address - Phone:706-646-4508
Practice Address - Fax:706-646-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041918174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040013774OtherRAIL ROAD MEDICARE
GA584912OtherBLUE CROSS BLUE SHIELD
GA00711301CMedicaid
GA511G700284Medicare PIN
GA584912OtherBLUE CROSS BLUE SHIELD