MEDICARE: PROVIDENCE EAR NOSE & THROAT ASSOCIATES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1134680747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE EAR NOSE & THROAT ASSOCIATES INC

Provider Business Mailing Address
First Line	:	2112 PROVIDENCE AVE
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013-5507
Country	:	US
Telephone Number	:	610-874-5366
Fax Number	:	610-874-8448

Provider Business Practice Location Address
First Line	:	RIDDLE MEM. HOSP.- OUTPT. PAV.
Second Line	:	1098 W. BALTIMORE PK. STE 3406
City	:	MEDIA
State	:	PA
Zip	:	19063-5139
Country	:	US
Telephone Number	:	610-874-5366
Fax Number	:	610-874-8448

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	JOHN M FEEHERY
Credential	:	MD
Telephone Number	:	610-874-5366

Provider Enumeration Date	:	03/27/2019
Last Update Date	:	04/14/2021

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Directions to “PROVIDENCE EAR NOSE & THROAT ASSOCIATES INC ” Practice Location

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