Provider Demographics
NPI:1770696833
Name:ENT SURGERY GROUP PC
Entity type:Organization
Organization Name:ENT SURGERY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VANDER ARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-761-4844
Mailing Address - Street 1:425 N 21ST ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2223
Mailing Address - Country:US
Mailing Address - Phone:717-761-4844
Mailing Address - Fax:717-761-8953
Practice Address - Street 1:425 N 21ST ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2223
Practice Address - Country:US
Practice Address - Phone:717-761-4844
Practice Address - Fax:717-761-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA048971EDXMedicare PIN
PAH40718Medicare UPIN
PAI06567Medicare UPIN
PA079216EDXMedicare PIN