Healthcare Provider Details

I. General information

NPI: 1114986163
Provider Name (Legal Business Name): EAR,NOSE,& THROAT OF NORTHWEST GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 JOHN MADDOX DR NW
ROME GA
30165-1419
US

IV. Provider business mailing address

107 JOHN MADDOX DR NW
ROME GA
30165-1419
US

V. Phone/Fax

Practice location:
  • Phone: 706-235-7008
  • Fax:
Mailing address:
  • Phone: 706-235-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number12408
License Number StateGA

VIII. Authorized Official

Name: DR. RAYMOND HOWARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-235-0116