Provider Demographics
NPI:1669490546
Name:MEDFORD EAR NOSE AND THROAT CLINIC PC
Entity Type:Organization
Organization Name:MEDFORD EAR NOSE AND THROAT CLINIC PC
Other - Org Name:OREGON EAR NOSE AND THROAT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-779-7331
Mailing Address - Street 1:1170 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6101
Mailing Address - Country:US
Mailing Address - Phone:541-779-7331
Mailing Address - Fax:541-779-3522
Practice Address - Street 1:1170 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6101
Practice Address - Country:US
Practice Address - Phone:541-779-7331
Practice Address - Fax:541-779-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR00WCGQCMedicare PIN