Provider Demographics
NPI:1649629957
Name:EAR NOSE AND THROAT CONSULTANTS
Entity type:Organization
Organization Name:EAR NOSE AND THROAT CONSULTANTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JERDEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-217-4320
Mailing Address - Street 1:101 TOWER ROAD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:605-217-4320
Mailing Address - Fax:605-217-2948
Practice Address - Street 1:101 TOWER ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-217-4320
Practice Address - Fax:605-217-2948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAR NOSE AND THROAT CONSULTANTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-07
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1919OtherSOUTH DAKOTA LICENSE