Healthcare Provider Details

I. General information

NPI: 1417958786
Provider Name (Legal Business Name): THOMASTON EAR, NOSE AND THROAT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CHEROKEE RD
THOMASTON GA
30286-3402
US

IV. Provider business mailing address

210 CHEROKEE RD
THOMASTON GA
30286-3402
US

V. Phone/Fax

Practice location:
  • Phone: 706-646-4508
  • Fax: 706-646-2752
Mailing address:
  • Phone: 706-646-4508
  • Fax: 706-646-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number041918
License Number StateGA

VIII. Authorized Official

Name: DR. KEVIN ANTHONY O'CONNELL
Title or Position: PHYSICIAN/PRESIDENT
Credential: MD
Phone: 706-646-4508