Healthcare Provider Details

I. General information

NPI: 1154445930
Provider Name (Legal Business Name): EAR NOSE THROAT & SPECIALIST-CHEROKEE SINUS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 RIVERSTONE DR
CANTON GA
30114-5256
US

IV. Provider business mailing address

215 RIVERSTONE DR
CANTON GA
30114-5256
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-6600
  • Fax: 770-345-6611
Mailing address:
  • Phone: 770-345-6600
  • Fax: 770-345-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number030684
License Number StateGA

VIII. Authorized Official

Name: RONALD VAN TUYL JR.
Title or Position: PHYSICIAN
Credential:
Phone: 770-345-6600