Healthcare Provider Details

I. General information

NPI: 1689732836
Provider Name (Legal Business Name): COMMONWEALTH EAR NOSE & THROAT-HEAD & NECK CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT 8033
CAROL STREAM IL
60122-8033
US

IV. Provider business mailing address

4004 DUPONT CIRCLE
LOUISVILLE KY
40207
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-0159
  • Fax:
Mailing address:
  • Phone: 502-893-0159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. HARRIET G SELLERS
Title or Position: CERTIFIED CODING PROFESSIONAL
Credential:
Phone: 502-893-0159