Provider Demographics
NPI:1932177805
Name:CANONICO EAR, NOSE AND THROAT, P.C.
Entity Type:Organization
Organization Name:CANONICO EAR, NOSE AND THROAT, P.C.
Other - Org Name:EAR, NOSE AND THROAT ASSOCIATES OF MIDDLE TENNESSEE, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANDIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-684-3504
Mailing Address - Street 1:507 NW ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3504
Mailing Address - Country:US
Mailing Address - Phone:931-393-4332
Mailing Address - Fax:931-393-2304
Practice Address - Street 1:507 NW ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3504
Practice Address - Country:US
Practice Address - Phone:931-393-4332
Practice Address - Fax:931-393-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4064287OtherBLUECROSS BLUESHIELD
TN3710667Medicaid
TN3710667OtherRAILROAD MEDICARE
TN3710667Medicare PIN