Healthcare Provider Details

I. General information

NPI: 1174803076
Provider Name (Legal Business Name): EAR, NOSE & THROAT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST PPE 601
BALTIMORE MD
21204-6800
US

IV. Provider business mailing address

6565 N CHARLES ST PPE 601
BALTIMORE MD
21204-6800
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-5151
  • Fax: 410-823-8309
Mailing address:
  • Phone: 410-821-5151
  • Fax: 410-823-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number667638
License Number StateMD

VIII. Authorized Official

Name: MRS. DENISE WINGERD
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-821-5154