Provider Demographics
NPI:1609942382
Name:EAR NOSE & THROAT ALLERGY & FACIAL PLASTIC SURGERY SPECIALISTS LLC
Entity Type:Organization
Organization Name:EAR NOSE & THROAT ALLERGY & FACIAL PLASTIC SURGERY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER & MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:CHERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-256-3338
Mailing Address - Street 1:2600 POST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1258
Mailing Address - Country:US
Mailing Address - Phone:203-256-3338
Mailing Address - Fax:203-256-3346
Practice Address - Street 1:2600 POST RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1258
Practice Address - Country:US
Practice Address - Phone:203-256-3338
Practice Address - Fax:203-256-3346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT040000347Medicare PIN