Provider Demographics
NPI:1508999236
Name:CANTON EAR NOSE AND THROAT CLINIC, P.C.
Entity Type:Organization
Organization Name:CANTON EAR NOSE AND THROAT CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-924-1915
Mailing Address - Street 1:8294 HIGHWAY 92
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3672
Mailing Address - Country:US
Mailing Address - Phone:770-924-1915
Mailing Address - Fax:770-516-9629
Practice Address - Street 1:8294 HIGHWAY 92
Practice Address - Street 2:SUITE 110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3672
Practice Address - Country:US
Practice Address - Phone:770-924-1915
Practice Address - Fax:770-516-9629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026511174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45274Medicare UPIN
GAGRP4881Medicare PIN