Healthcare Provider Details

I. General information

NPI: 1619012010
Provider Name (Legal Business Name): AFFILIATED EAR, NOSE AND THROAT PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 WASHINGTON ST
INGLESIDE IL
60041-9208
US

IV. Provider business mailing address

2441 LAKE SHORE DR
WOODSTOCK IL
60098-6911
US

V. Phone/Fax

Practice location:
  • Phone: 847-587-4700
  • Fax: 847-587-6034
Mailing address:
  • Phone: 815-338-4600
  • Fax: 815-338-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: FAY WILSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 815-338-4600