Healthcare Provider Details

I. General information

NPI: 1568494748
Provider Name (Legal Business Name): FREEPORT EAR NOSE & THROAT ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 S KUNKLE BLVD
FREEPORT IL
61032-6914
US

IV. Provider business mailing address

1030 S KUNKLE BLVD
FREEPORT IL
61032-6914
US

V. Phone/Fax

Practice location:
  • Phone: 815-235-7673
  • Fax: 815-235-1310
Mailing address:
  • Phone: 815-235-7673
  • Fax: 815-235-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. SHAWN ALLEN SHIANNA
Title or Position: OWNER
Credential: MD
Phone: 815-235-7673