Provider Demographics
NPI:1497924229
Name:ENT SURGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:ENT SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-833-9600
Mailing Address - Street 1:2376 N 400 E
Mailing Address - Street 2:STE 202
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9838
Mailing Address - Country:US
Mailing Address - Phone:435-833-9600
Mailing Address - Fax:435-882-4743
Practice Address - Street 1:2376 N 400 E
Practice Address - Street 2:202
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9838
Practice Address - Country:US
Practice Address - Phone:435-833-9600
Practice Address - Fax:435-882-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058022Medicare PIN