Provider Demographics
NPI:1184750127
Name:ILLINOIS EAR, NOSE AND THROAT ASSOCIATES, P.C
Entity type:Organization
Organization Name:ILLINOIS EAR, NOSE AND THROAT ASSOCIATES, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-451-1800
Mailing Address - Street 1:2120 MADISON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4744
Mailing Address - Country:US
Mailing Address - Phone:618-451-1800
Mailing Address - Fax:618-451-1526
Practice Address - Street 1:2120 MADISON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4744
Practice Address - Country:US
Practice Address - Phone:618-451-1800
Practice Address - Fax:618-451-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060002662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CF4039OtherMEDICARE RAILROAD
MO001013746Medicare PIN
MO001013747Medicare PIN