Provider Demographics
NPI:1912090390
Name:AFFILIATED OTOLARYNGOLOGISTS PA
Entity Type:Organization
Organization Name:AFFILIATED OTOLARYNGOLOGISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ELEANORE
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-494-9882
Mailing Address - Street 1:12000 ELM CREEK BLVD
Mailing Address - Street 2:#L20
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7163
Mailing Address - Country:US
Mailing Address - Phone:763-494-9882
Mailing Address - Fax:763-494-9883
Practice Address - Street 1:12000 ELM CREEK BLVD
Practice Address - Street 2:#L20
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9883
Practice Address - Country:US
Practice Address - Phone:763-494-9882
Practice Address - Fax:763-494-9883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18878207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D8133604Medicare UPIN