MEDICARE: RUSSELLVILLE EAR NOSE AND THROAT SURGERY CLINIC, P.A.

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	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	57789	OTHER	AR	ARK. BCBS

General Provider Information

NPI Number	:	1306814116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE EAR NOSE AND THROAT SURGERY CLINIC, P.A.

Provider Business Mailing Address
First Line	:	106 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-5261
Fax Number	:	479-968-4761

Provider Business Practice Location Address
First Line	:	106 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-5261
Fax Number	:	479-968-4761

Authorized Official
Title or Position	:	OWNER
Name	:	MR. NATHAN F. AUSTIN
Credential	:	M.D.
Telephone Number	:	479-968-5261

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	08/22/2020

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