Provider Demographics
NPI:1760577787
Name:FIFTH AVENUE OTOLARYNGOLOGISTS, INC.
Entity Type:Organization
Organization Name:FIFTH AVENUE OTOLARYNGOLOGISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICCIARDULLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-629-2144
Mailing Address - Street 1:7227 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4853
Mailing Address - Country:US
Mailing Address - Phone:330-629-2144
Mailing Address - Fax:330-629-2140
Practice Address - Street 1:7227 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4853
Practice Address - Country:US
Practice Address - Phone:330-629-2144
Practice Address - Fax:330-629-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50088404207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
278113OtherKEYSTONE HEALTH PLAN
OH000000252392OtherANTHEM GROUP ID
099857OtherHIGHMARK
OH0666819Medicaid
CE5013OtherRAILROAD MEDICARE
OH000000252392OtherANTHEM GROUP ID
OH0666819Medicaid
OH=========OtherUHC GROUP ID
=========OtherCIGNA
=========OtherSELECT BLUE
OH=========OtherMEDICAL MUTUAL GROUP ID
=========OtherHUMANA
CE5013OtherRAILROAD MEDICARE
278113OtherKEYSTONE HEALTH PLAN
OH=========OtherMEDICAL MUTUAL GROUP ID
FI9217552Medicare PIN