Provider Demographics
NPI:1255607891
Name:EAR, NOSE, THROAT & SINUS CLINIC, LLC
Entity type:Organization
Organization Name:EAR, NOSE, THROAT & SINUS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-532-6165
Mailing Address - Street 1:106 E C ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5411
Mailing Address - Country:US
Mailing Address - Phone:308-532-6165
Mailing Address - Fax:308-532-7464
Practice Address - Street 1:106 E C ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5411
Practice Address - Country:US
Practice Address - Phone:308-532-6165
Practice Address - Fax:308-532-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE53752953300Medicaid
NE099761Medicare PIN
NE53752953300Medicaid