Healthcare Provider Details

I. General information

NPI: 1366572158
Provider Name (Legal Business Name): EAR NOSE AND THROAT ASSOCIATES OF GRANTS PASS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 NW 6TH ST SOUTH SUITE
GRANTS PASS OR
97526-1094
US

IV. Provider business mailing address

1600 NW 6TH ST SOUTH SUITE
GRANTS PASS OR
97526-1094
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-7775
  • Fax: 541-476-3572
Mailing address:
  • Phone: 541-476-7775
  • Fax: 541-476-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD19356
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberDO20532
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD10466
License Number StateOR

VIII. Authorized Official

Name: JEANNE REECE
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-476-7775