Provider Demographics
NPI:1689782427
Name:ADVANCED EAR NOSE & THROAT SPECIALISTS, SC
Entity Type:Organization
Organization Name:ADVANCED EAR NOSE & THROAT SPECIALISTS, SC
Other - Org Name:ADVENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MADAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KANDULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-938-3838
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-938-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:2885 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4404
Practice Address - Country:US
Practice Address - Phone:888-889-3838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44930 020207YX0007X
WI434 156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34336200Medicaid
WI000068202Medicare ID - Type Unspecified
WIH78750Medicare UPIN