Healthcare Provider Details

I. General information

NPI: 1912243270
Provider Name (Legal Business Name): EAR, NOSE, & THROAT MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 BILBY RD SUITE 301
HACKETTSTOWN NJ
07840-4174
US

IV. Provider business mailing address

108 BILBY RD SUITE 301
HACKETTSTOWN NJ
07840-4174
US

V. Phone/Fax

Practice location:
  • Phone: 908-979-0662
  • Fax: 908-979-0713
Mailing address:
  • Phone: 908-979-0662
  • Fax: 908-979-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMA63710
License Number StateNJ

VIII. Authorized Official

Name: DR. VICTOR GERARD GENTILE
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 908-979-0662