MEDICARE: EAR, NOSE & THROAT INSTITUTE OF SOUTHERN ILLINOIS LTD.

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	042.000860	IL

General Provider Information

NPI Number	:	1194825174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAR, NOSE & THROAT INSTITUTE OF SOUTHERN ILLINOIS LTD.

Provider Business Mailing Address
First Line	:	19 WOLF CREEK DR
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-2355
Country	:	US
Telephone Number	:	618-235-3687
Fax Number	:	618-239-9492

Provider Business Practice Location Address
First Line	:	19 WOLF CREEK DR
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-2355
Country	:	US
Telephone Number	:	618-235-3687
Fax Number	:	618-239-9492

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MURRAY DANIEL MCGRADY
Credential	:	M.D.
Telephone Number	:	618-235-3687

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	06/30/2008

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