Healthcare Provider Details

I. General information

NPI: 1063746709
Provider Name (Legal Business Name): ENT OF ATHENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NACOOCHEE AVE
ATHENS GA
30601-1823
US

IV. Provider business mailing address

150 NACOOCHEE AVE
ATHENS GA
30601-1823
US

V. Phone/Fax

Practice location:
  • Phone: 706-546-7908
  • Fax: 706-546-1944
Mailing address:
  • Phone: 706-546-7908
  • Fax: 706-546-1944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number052997
License Number StateGA

VIII. Authorized Official

Name: AMY ELLIS
Title or Position: BILLING MANAGER
Credential:
Phone: 706-546-7908