Provider Demographics
NPI:1750340949
Name:EAR, NOSE & THROAT SPECIALISTS OF ILLINOIS LTD
Entity type:Organization
Organization Name:EAR, NOSE & THROAT SPECIALISTS OF ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WALNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-674-5585
Mailing Address - Street 1:2604 DEMPSTER ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8429
Mailing Address - Country:US
Mailing Address - Phone:847-674-5585
Mailing Address - Fax:
Practice Address - Street 1:2604 DEMPSTER ST STE 501
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8429
Practice Address - Country:US
Practice Address - Phone:847-674-5585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-001273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL604340Medicare PIN
IL1750340949Medicare PIN