Healthcare Provider Details

I. General information

NPI: 1821176967
Provider Name (Legal Business Name): NORTHWEST ENT ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LACY ST NW
MARIETTA GA
30060
US

IV. Provider business mailing address

80 LACY ST NW
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0368
  • Fax: 678-581-5969
Mailing address:
  • Phone: 770-427-0368
  • Fax: 678-581-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number041239
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36884
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number31970
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLOS M. EGEA
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-427-0368