Provider Demographics
NPI:1790797728
Name:TALLAHASSEE EAR, NOSE & THROAT-HEAD & NECK SURGERY, P.A.
Entity Type:Organization
Organization Name:TALLAHASSEE EAR, NOSE & THROAT-HEAD & NECK SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUACKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:CRM
Authorized Official - Phone:850-877-0101
Mailing Address - Street 1:1405 CENTERVILLE ROAD
Mailing Address - Street 2:SUITE 5400
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4629
Mailing Address - Country:US
Mailing Address - Phone:850-877-0101
Mailing Address - Fax:850-877-2750
Practice Address - Street 1:1405 CENTERVILLE RD
Practice Address - Street 2:SUITE 5400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4655
Practice Address - Country:US
Practice Address - Phone:850-877-0101
Practice Address - Fax:850-877-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33294OtherBCBS GROUP PROVIDER NUMBE
FL054317900Medicaid
FL054317900Medicaid