Provider Demographics
NPI:1922236074
Name:PROVIDENT EAR NOSE AND THROAT LLC
Entity Type:Organization
Organization Name:PROVIDENT EAR NOSE AND THROAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-284-9869
Mailing Address - Street 1:101 S VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3571
Mailing Address - Country:US
Mailing Address - Phone:864-284-9869
Mailing Address - Fax:864-284-9882
Practice Address - Street 1:101 S VENTURE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3571
Practice Address - Country:US
Practice Address - Phone:864-232-4846
Practice Address - Fax:888-451-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18523207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT25960Medicaid
SCT25960Medicaid