Provider Demographics
NPI:1619039815
Name:CLOVE LAKES ENT PC
Entity Type:Organization
Organization Name:CLOVE LAKES ENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:HYOSUN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-596-7063
Mailing Address - Street 1:1414 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:718-447-1261
Mailing Address - Fax:718-981-1856
Practice Address - Street 1:1414 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-447-1261
Practice Address - Fax:718-981-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWGW131Medicare ID - Type Unspecified