Provider Demographics
NPI:1578747408
Name:NORTHWEST OTOLARYNGOLOGY, INC
Entity Type:Organization
Organization Name:NORTHWEST OTOLARYNGOLOGY, INC
Other - Org Name:NORTHWEST OTOLARYNGOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDZINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-379-6006
Mailing Address - Street 1:12255 DE PAUL DR STE 830N
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-291-5307
Mailing Address - Fax:314-291-0838
Practice Address - Street 1:12255 DE PAUL DR STE 830N
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-291-5307
Practice Address - Fax:314-291-0838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000013172Medicare PIN