Provider Demographics
NPI:1558376004
Name:ADVANCED OTOLARYNGOLOGY SERVICES PA
Entity Type:Organization
Organization Name:ADVANCED OTOLARYNGOLOGY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-399-5311
Mailing Address - Street 1:3627 UNIVERSITY BLVD S STE 210
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4256
Mailing Address - Country:US
Mailing Address - Phone:904-399-5311
Mailing Address - Fax:904-396-2520
Practice Address - Street 1:3627 UNIVERSITY BLVD S STE 210
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4256
Practice Address - Country:US
Practice Address - Phone:904-399-5311
Practice Address - Fax:904-396-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F51276Medicare UPIN
40870Medicare PIN