Provider Demographics
NPI:1689732836
Name:COMMONWEALTH EAR NOSE & THROAT-HEAD & NECK CENTER
Entity Type:Organization
Organization Name:COMMONWEALTH EAR NOSE & THROAT-HEAD & NECK CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED CODING PROFESSIONAL
Authorized Official - Prefix:MS
Authorized Official - First Name:HARRIET
Authorized Official - Middle Name:G
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-893-0159
Mailing Address - Street 1:4004 DUPONT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT 8033
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60122-8033
Practice Address - Country:US
Practice Address - Phone:502-893-0159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB7082OtherRR MEDICARE PIN NUMBER
IN100011000AMedicaid
KY65912396Medicaid
KY0986Medicare PIN
IN100011000AMedicaid