Provider Demographics
NPI:1477764942
Name:MIDWEST EAR NOSE & THROAT CLINIC, S.C.
Entity Type:Organization
Organization Name:MIDWEST EAR NOSE & THROAT CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-993-0307
Mailing Address - Street 1:3316 PATRIOT CT
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3782
Mailing Address - Country:US
Mailing Address - Phone:618-993-0307
Mailing Address - Fax:618-993-0807
Practice Address - Street 1:3316 PATRIOT CT
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3782
Practice Address - Country:US
Practice Address - Phone:618-993-0307
Practice Address - Fax:618-993-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
208525Medicare PIN
205790Medicare PIN
ILDA3024Medicare PIN