Provider Demographics
NPI:1336126820
Name:ENT SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:ENT SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HRAIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOUTNOUYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-241-2101
Mailing Address - Street 1:1505 WILSON TER
Mailing Address - Street 2:#270
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4071
Mailing Address - Country:US
Mailing Address - Phone:818-241-2101
Mailing Address - Fax:818-241-2166
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:#270
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-241-2101
Practice Address - Fax:818-241-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACJ8786OtherRAILROAD MEDICARE
CAZZZ61447ZOtherBLUE SHIELD
CAGR0088300Medicaid
CACJ8787OtherRAILROAD MEDICARE
CAZZZ56084ZOtherBLUE SHIELD
CAZZZ56084ZOtherBLUE SHIELD
CAW14884Medicare ID - Type Unspecified