Provider Demographics
NPI:1821176967
Name:NORTHWEST ENT ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHWEST ENT ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:M
Authorized Official - Last Name:EGEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-427-0368
Mailing Address - Street 1:80 LACY ST NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-427-0368
Mailing Address - Fax:678-581-5969
Practice Address - Street 1:80 LACY ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-427-0368
Practice Address - Fax:678-581-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36884207Y00000X
GA31970207Y00000X
GA041239207YX0905X
207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00403851EMedicaid
GA10041532Medicaid
GA00868524BMedicaid
GA00553385CMedicaid
GA303310Medicaid
GA310744Medicaid
GA310745Medicaid
GA582064647Medicaid
GA04BDCGLMedicare PIN
GA00868524BMedicaid
GA00403851EMedicaid
GA00553385CMedicaid
GAF63935Medicare UPIN
GA10041532Medicaid
GA04BDCGQMedicare PIN