Provider Demographics
NPI:1881017424
Name:ETOWAH EAR NOSE & THROAT, LLC
Entity type:Organization
Organization Name:ETOWAH EAR NOSE & THROAT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:OSTERDORF
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:256-438-5821
Mailing Address - Street 1:PO BOX 8365
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902-8365
Mailing Address - Country:US
Mailing Address - Phone:256-543-2867
Mailing Address - Fax:256-459-4791
Practice Address - Street 1:1026 GOODYEAR AVE - STE. 100B
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1194
Practice Address - Country:US
Practice Address - Phone:256-438-5821
Practice Address - Fax:256-467-4262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD27282207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009912008Medicaid
AL009912008Medicaid
ALI25274Medicare UPIN