Provider Demographics
NPI:1619012010
Name:AFFILIATED EAR, NOSE AND THROAT PHYSICIANS
Entity Type:Organization
Organization Name:AFFILIATED EAR, NOSE AND THROAT PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-338-4600
Mailing Address - Street 1:2441 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-6911
Mailing Address - Country:US
Mailing Address - Phone:815-338-4600
Mailing Address - Fax:815-338-4611
Practice Address - Street 1:214 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:IL
Practice Address - Zip Code:60041-9208
Practice Address - Country:US
Practice Address - Phone:847-587-4700
Practice Address - Fax:847-587-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID
IL211526Medicare ID - Type UnspecifiedLOCALITY 15