Provider Demographics
NPI:1467720722
Name:EAR, NOSE & THROAT MEDICAL ASSOCIATES OF THE PENINSULA, INC
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT MEDICAL ASSOCIATES OF THE PENINSULA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCK HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-344-6896
Mailing Address - Street 1:322 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2214
Mailing Address - Country:US
Mailing Address - Phone:650-344-6896
Mailing Address - Fax:650-344-2794
Practice Address - Street 1:100 S ELLSWORTH AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3939
Practice Address - Country:US
Practice Address - Phone:650-344-6896
Practice Address - Fax:650-344-2794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG071603207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF17538Medicare UPIN