Provider Demographics
NPI:1689668915
Name:CENTRAL EAR NOSE & THROAT ASSOC PC
Entity Type:Organization
Organization Name:CENTRAL EAR NOSE & THROAT ASSOC PC
Other - Org Name:CENTRAL ENT ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT / CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-755-3161
Mailing Address - Street 1:295 LINCOLN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3639
Mailing Address - Country:US
Mailing Address - Phone:508-755-3161
Mailing Address - Fax:
Practice Address - Street 1:295 LINCOLN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3639
Practice Address - Country:US
Practice Address - Phone:508-755-3161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA35665207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2626263Medicaid
N60101Medicare ID - Type Unspecified
B76816Medicare UPIN