Provider Demographics
NPI:1568593754
Name:MIDWEST EAR NOSE & THROAT LTD
Entity Type:Organization
Organization Name:MIDWEST EAR NOSE & THROAT LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-988-7777
Mailing Address - Street 1:3 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3838
Mailing Address - Country:US
Mailing Address - Phone:312-988-7777
Mailing Address - Fax:312-988-7838
Practice Address - Street 1:3 E HURON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3838
Practice Address - Country:US
Practice Address - Phone:312-988-7777
Practice Address - Fax:312-988-7838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053430207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31620670OtherBLUE CROSS BLUE SHIELD
IL036059430Medicaid
IL31620670OtherBLUE CROSS BLUE SHIELD
IL371790Medicare ID - Type Unspecified