Provider Demographics
NPI:1568572907
Name:SOUTH SUBURBAN EAR, NOSE & THROAT ASSOC INC
Entity Type:Organization
Organization Name:SOUTH SUBURBAN EAR, NOSE & THROAT ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-337-7635
Mailing Address - Street 1:825 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1659
Mailing Address - Country:US
Mailing Address - Phone:781-337-3424
Mailing Address - Fax:781-337-7569
Practice Address - Street 1:825 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1659
Practice Address - Country:US
Practice Address - Phone:781-337-3424
Practice Address - Fax:781-337-7569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9709517Medicaid
MA9709517Medicaid