Healthcare Provider Details

I. General information

NPI: 1437153285
Provider Name (Legal Business Name): MIDWEST EAR NOSE AND THROAT SURGERY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PROFESSIONAL BLVD
EVANSVILLE IN
47714-8014
US

IV. Provider business mailing address

1401 PROFESSIONAL BLVD
EVANSVILLE IN
47714-8014
US

V. Phone/Fax

Practice location:
  • Phone: 812-473-2060
  • Fax: 812-473-0763
Mailing address:
  • Phone: 812-473-2060
  • Fax: 812-473-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JESSICA DENTON
Title or Position: CREDENTIALING REP
Credential:
Phone: 812-473-2060