Provider Demographics
NPI:1831225465
Name:JACKSON ENT CLINIC , PSC
Entity type:Organization
Organization Name:JACKSON ENT CLINIC , PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARIQ
Authorized Official - Middle Name:A
Authorized Official - Last Name:SARTAWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-666-9909
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0768
Mailing Address - Country:US
Mailing Address - Phone:606-666-9909
Mailing Address - Fax:606-666-9982
Practice Address - Street 1:1550 HIGHWAY 15 S STE 29
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9221
Practice Address - Country:US
Practice Address - Phone:606-666-9909
Practice Address - Fax:606-666-9982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36227204E00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYSA64023724Medicaid
KYSA64023724Medicaid
H27095Medicare UPIN