Provider Demographics
NPI:1679835086
Name:EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:EAR NOSE & THROAT MEDICAL AND SURGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:CZIBULKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-234-1324
Mailing Address - Street 1:31 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2304
Mailing Address - Country:US
Mailing Address - Phone:203-234-1324
Mailing Address - Fax:203-239-3047
Practice Address - Street 1:46 PRINCE ST STE 601
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1634
Practice Address - Country:US
Practice Address - Phone:203-752-1726
Practice Address - Fax:203-752-1838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004907363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty