Provider Demographics
NPI:1295735850
Name:EAR NOSE & THROAT ASSC OF CHARL INC
Entity type:Organization
Organization Name:EAR NOSE & THROAT ASSC OF CHARL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SPORCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-340-2225
Mailing Address - Street 1:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25326-1628
Mailing Address - Country:US
Mailing Address - Phone:304-340-2225
Mailing Address - Fax:304-340-2204
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-342-0124
Practice Address - Fax:304-340-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008888000Medicaid
WVCA7089OtherRR MEDICARE
WV0778148001OtherCIGNA
WV0778148001OtherCIGNA