Provider Demographics
NPI:1740239318
Name:FOOTHILLS E.N.T., PA
Entity Type:Organization
Organization Name:FOOTHILLS E.N.T., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-859-1912
Mailing Address - Street 1:201 RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-1442
Mailing Address - Country:US
Mailing Address - Phone:864-859-1912
Mailing Address - Fax:864-855-9836
Practice Address - Street 1:201 RICHARD ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1442
Practice Address - Country:US
Practice Address - Phone:864-859-1912
Practice Address - Fax:864-855-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0411Medicaid
SC4029Medicare PIN