Provider Demographics
NPI:1477681823
Name:INSTITUTE OF ADVANCED ENT SURGERY LLC
Entity Type:Organization
Organization Name:INSTITUTE OF ADVANCED ENT SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:2200 PUMP RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-3539
Mailing Address - Country:US
Mailing Address - Phone:804-747-7427
Mailing Address - Fax:804-747-7429
Practice Address - Street 1:2200 PUMP RD
Practice Address - Street 2:SUITE 240
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3539
Practice Address - Country:US
Practice Address - Phone:804-747-7427
Practice Address - Fax:804-747-7429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477681823Medicaid