Healthcare Provider Details

I. General information

NPI: 1457321721
Provider Name (Legal Business Name): TRI-STATE EAR, NOSE, AND THROAT SURGEONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COLUMBIA ST SUITE 310
EVANSVILLE IN
47710-1782
US

IV. Provider business mailing address

350 W COLUMBIA ST SUITE 310
EVANSVILLE IN
47710-1782
US

V. Phone/Fax

Practice location:
  • Phone: 812-425-4646
  • Fax: 812-467-7209
Mailing address:
  • Phone: 812-425-4646
  • Fax: 812-467-7209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number50001145A
License Number StateIN

VIII. Authorized Official

Name: DAVID T. WAHLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 812-425-4646