Provider Demographics
NPI:1720208820
Name:EAR NOSE & THROAT MEDICINE & SURGERY OF PORTSMOUTH PA
Entity Type:Organization
Organization Name:EAR NOSE & THROAT MEDICINE & SURGERY OF PORTSMOUTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:Y
Authorized Official - Last Name:YEGANEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-431-3477
Mailing Address - Street 1:330 BORTHWICK AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7109
Mailing Address - Country:US
Mailing Address - Phone:603-431-3477
Mailing Address - Fax:603-430-9663
Practice Address - Street 1:330 BORTHWICK AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7109
Practice Address - Country:US
Practice Address - Phone:603-431-3477
Practice Address - Fax:603-430-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH5840207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010589Medicaid
NH30010589Medicaid
NHB86138Medicare UPIN