Provider Demographics
NPI:1871673046
Name:BUFFALO TRACE EAR, NOSE & THROAT CENTER
Entity Type:Organization
Organization Name:BUFFALO TRACE EAR, NOSE & THROAT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:SASSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-759-5286
Mailing Address - Street 1:4980 AA HWY N
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:KY
Mailing Address - Zip Code:41043-9271
Mailing Address - Country:US
Mailing Address - Phone:606-747-5077
Mailing Address - Fax:606-759-5773
Practice Address - Street 1:1925 OLD MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8984
Practice Address - Country:US
Practice Address - Phone:606-759-5286
Practice Address - Fax:606-759-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34006187S174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000050862OtherANTHEM ID NUMBER
KY64024201Medicaid
OH0986107Medicaid
KY64024201Medicaid