Healthcare Provider Details

I. General information

NPI: 1265865232
Provider Name (Legal Business Name): EAR, NOSE, THROAT, AND ALLERGY SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80A INTERSTATE SOUTH DR
JASPER GA
30143-6226
US

IV. Provider business mailing address

80A INTERSTATE SOUTH DR
JASPER GA
30143-6226
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 Code207Y00000X
TaxonomyOtolaryngology Physician
License Number30684
License Number StateGA

VIII. Authorized Official

Name: DR. RONALD VAN TUYL JR.
Title or Position: PRESIDENT
Credential: M.D
Phone: 770-345-6600