Provider Demographics
NPI:1609019363
Name:OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A,.
Entity Type:Organization
Organization Name:OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A,.
Other - Org Name:MIDWEST EAR, NOSE & THROAT SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-702-0750
Mailing Address - Street 1:2080 WOODWINDS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2524
Mailing Address - Country:US
Mailing Address - Phone:651-702-0750
Mailing Address - Fax:651-645-6166
Practice Address - Street 1:2080 WOODWINDS DR STE 240
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2539
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:651-645-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1821195959OtherMEDICARE PTAN C00273
MN1821195959Medicaid