Provider Demographics
NPI:1134181456
Name:ENT CARE PC
Entity type:Organization
Organization Name:ENT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-790-9620
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-4788
Mailing Address - Fax:334-793-1561
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 403
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-4788
Practice Address - Fax:334-793-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF251Medicare PIN