Healthcare Provider Details

I. General information

NPI: 1598747768
Provider Name (Legal Business Name): ENT SURGICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 NORTH 400 EAST SUITE 202
TOOELE UT
84074
US

IV. Provider business mailing address

2376 NORTH 400 EAST SUITE 202
TOOELE UT
84074
US

V. Phone/Fax

Practice location:
  • Phone: 435-833-9600
  • Fax:
Mailing address:
  • Phone: 435-833-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number58686931205
License Number StateUT

VIII. Authorized Official

Name: PETER VENTURA
Title or Position: PRESIDENT
Credential: MD
Phone: 435-833-9600