Provider Demographics
NPI:1821163577
Name:EAR, NOSE & THROAT PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-838-3903
Mailing Address - Street 1:6130 PRESTLEY MILL RD STE C
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2288
Mailing Address - Country:US
Mailing Address - Phone:678-838-3903
Mailing Address - Fax:678-838-7454
Practice Address - Street 1:6130 PRESTLEY MILL RD STE C
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2288
Practice Address - Country:US
Practice Address - Phone:678-838-3903
Practice Address - Fax:678-838-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH6392OtherRAILROAD MEDICARE
GAGRP4950Medicare ID - Type Unspecified