MEDICARE: ENT SURGICAL ASSOCIATES

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CJ8786	OTHER	CA	RAILROAD MEDICARE
4	CJ8787	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	ZZZ61447Z	OTHER	CA	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	ZZZ56084Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1336126820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENT SURGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	1505 WILSON TER
Second Line	:	#270
City	:	GLENDALE
State	:	CA
Zip	:	91206-4071
Country	:	US
Telephone Number	:	818-241-2101
Fax Number	:	818-241-2166

Provider Business Practice Location Address
First Line	:	1505 WILSON TER
Second Line	:	#270
City	:	GLENDALE
State	:	CA
Zip	:	91206-4071
Country	:	US
Telephone Number	:	818-241-2101
Fax Number	:	818-241-2166

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. HRAIR A KOUTNOUYAN
Credential	:	MD
Telephone Number	:	818-241-2101

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	03/09/2012

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1063499937 — DR. HRAIR A KOUTNOUYAN MD
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Directions to “ENT SURGICAL ASSOCIATES ” Practice Location

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