Provider Demographics
NPI:1831911395
Name:NEXT WAVE PEDIATRIC ENT LLC
Entity type:Organization
Organization Name:NEXT WAVE PEDIATRIC ENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-696-5929
Mailing Address - Street 1:1940 ROUTE 70 E STE 1
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2141
Mailing Address - Country:US
Mailing Address - Phone:609-696-5929
Mailing Address - Fax:609-696-5619
Practice Address - Street 1:1940 ROUTE 70 E STE 1
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2141
Practice Address - Country:US
Practice Address - Phone:609-696-5929
Practice Address - Fax:609-696-5619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09871200OtherNEW JERSEY BOARD OF MEDICAL EXAMINERS
NJ0514390Medicaid