Provider Demographics
NPI:1841480746
Name:EAR MEDICAL GROUP A PC
Entity type:Organization
Organization Name:EAR MEDICAL GROUP A PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-227-3666
Mailing Address - Street 1:911 NW 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2324
Mailing Address - Country:US
Mailing Address - Phone:503-227-3666
Mailing Address - Fax:503-227-2234
Practice Address - Street 1:911 NW 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2324
Practice Address - Country:US
Practice Address - Phone:503-227-3666
Practice Address - Fax:503-227-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07645207YX0602X
ORMD 06745207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCJDLMedicare PIN