Provider Demographics
NPI:1497758155
Name:SACRAMENTO EAR NOSE & THROAT SURGICAL & MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SACRAMENTO EAR NOSE & THROAT SURGICAL & MEDICAL GROUP INC
Other - Org Name:SACRAMENTO EAR, NOSE, & THROAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-736-6670
Mailing Address - Street 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4300
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-233-4171
Practice Address - Street 1:1111 EXPOSITION BLVD
Practice Address - Street 2:BLDG 700
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4300
Practice Address - Country:US
Practice Address - Phone:916-736-6670
Practice Address - Fax:916-233-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5499OtherRR MEDICARE PIN
CAGR0010460Medicaid
CAGR0010460Medicaid