Provider Demographics
NPI:1811007487
Name:ENT R NET PA
Entity Type:Organization
Organization Name:ENT R NET PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-879-0060
Mailing Address - Street 1:4190 CITY LINE AVENUE
Mailing Address - Street 2:SUITE 526
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1635
Mailing Address - Country:US
Mailing Address - Phone:215-879-0060
Mailing Address - Fax:215-879-0063
Practice Address - Street 1:4190 CITY LINE AVENUE
Practice Address - Street 2:SUITE 526
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1635
Practice Address - Country:US
Practice Address - Phone:215-879-0060
Practice Address - Fax:215-879-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30723AOtherKEYSTONE MERCY HEALTH PLA
PA0007250440006Medicaid
PA0007250440006Medicaid