Provider Demographics
NPI:1760569545
Name:HEAD AND NECK SURGERY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:HEAD AND NECK SURGERY ASSOCIATES, PSC
Other - Org Name:ENT & ALLERGY SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-572-4104
Mailing Address - Street 1:40 N GRAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-4107
Mailing Address - Country:US
Mailing Address - Phone:859-781-4900
Mailing Address - Fax:859-572-3045
Practice Address - Street 1:40 N GRAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-4107
Practice Address - Country:US
Practice Address - Phone:859-781-4900
Practice Address - Fax:859-572-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Y00000X, 207YP0228X, 207YX0602X, 207YX0901X, 231H00000X, 363A00000X, 363L00000X, 363LF0000X
KY237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100015770Medicaid
KY7100266460Medicaid
OH701342Medicaid
KY65917965Medicaid
OH701342Medicaid
IN100015770Medicaid