Healthcare Provider Details

I. General information

NPI: 1184281735
Provider Name (Legal Business Name): ADVANCED EAR NOSE & THROAT SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N MILWAUKEE AVE UNIT 200
VERNON HILLS IL
60061-1637
US

IV. Provider business mailing address

10001 W INNOVATION DR STE 200
MILWAUKEE WI
53226-4851
US

V. Phone/Fax

Practice location:
  • Phone: 888-938-3838
  • Fax: 888-919-1083
Mailing address:
  • Phone: 888-938-3838
  • Fax: 888-919-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MADAN KANDULA
Title or Position: CEO
Credential: MD
Phone: 888-938-3838