Healthcare Provider Details

I. General information

NPI: 1326618448
Provider Name (Legal Business Name): NORTH BAY ENT & AUDIOLOGY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 UPPER CHESAPEAKE DR STE 206
BEL AIR MD
21014-4360
US

IV. Provider business mailing address

520 UPPER CHESAPEAKE DR STE 206
BEL AIR MD
21014-4360
US

V. Phone/Fax

Practice location:
  • Phone: 410-879-9100
  • Fax: 410-638-0408
Mailing address:
  • Phone: 410-879-9100
  • Fax: 410-638-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: JANELLE ADOLPH
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 410-688-9753