Provider Demographics
NPI:1710065446
Name:ADVANCED EAR, NOSE & THROAT, PC
Entity Type:Organization
Organization Name:ADVANCED EAR, NOSE & THROAT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MENACHOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-792-3242
Mailing Address - Street 1:7400 E CRESTLINE CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-3656
Mailing Address - Country:US
Mailing Address - Phone:303-792-3242
Mailing Address - Fax:303-792-9403
Practice Address - Street 1:7400 E CRESTLINE CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-3656
Practice Address - Country:US
Practice Address - Phone:303-792-3242
Practice Address - Fax:303-792-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31645207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01316454Medicaid
1275724932OtherNPI
CO1396871265OtherNPI
CO48138274Medicaid
CO1710065446OtherNPI
CO01316454Medicaid
CO1710065446OtherNPI
CO379808Medicare ID - Type Unspecified