Provider Demographics
NPI:1598840027
Name:EAR NOSE AND THROAT ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:EAR NOSE AND THROAT ASSOCIATES, P.C.
Other - Org Name:WATAUGA HEARING CONSERVATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:CCCA
Authorized Official - Phone:423-929-9101
Mailing Address - Street 1:215 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4671
Mailing Address - Country:US
Mailing Address - Phone:423-929-9101
Mailing Address - Fax:423-434-2032
Practice Address - Street 1:215 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4671
Practice Address - Country:US
Practice Address - Phone:423-929-9101
Practice Address - Fax:423-434-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA0000000247237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCA7519OtherRAILROAD MEDICARE
TN3373581OtherCIGNA MEDICARE
TN3373581OtherCIGNA MEDICARE