Healthcare Provider Details

I. General information

NPI: 1093936395
Provider Name (Legal Business Name): EAR, NOSE & THROAT INSTITUTE OF SOUTHERN ILLINOIS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 EE RD SUITE 205
COLUMBIA IL
62236-3445
US

IV. Provider business mailing address

19 WOLF CREEK DR
SWANSEA IL
62226-2355
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-3687
  • Fax: 618-239-9492
Mailing address:
  • Phone: 618-235-3687
  • Fax: 618-239-9492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARL W LEE II
Title or Position: SECRETARY
Credential: MD
Phone: 618-235-3687