Healthcare Provider Details

I. General information

NPI: 1760577787
Provider Name (Legal Business Name): FIFTH AVENUE OTOLARYNGOLOGISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 GLENWOOD AVE
YOUNGSTOWN OH
44512-4853
US

IV. Provider business mailing address

7227 GLENWOOD AVE
YOUNGSTOWN OH
44512-4853
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-2144
  • Fax: 330-629-2140
Mailing address:
  • Phone: 330-629-2144
  • Fax: 330-629-2140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number50088404
License Number StateOH

VIII. Authorized Official

Name: ANDREA R. RICCIARDULLI
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-629-2144