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General NPI Number Information
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NPI Number | 1407490105
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Entity Type | Organization
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Legal Business Name | EAR NOSE THROAT MEDICAL SERVICE
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Dates
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Enumeration Date | 11/05/2019
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Last Update Date | 10/03/2022
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Provider Practice Location Address
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Address Line | 226 S WOODS MILL RD STE 44W
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City | CHESTERFIELD
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State | MO
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Zip | 63017-3442
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Country | US
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Telephone | 314-447-4995
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Fax | 314-682-6093
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Provider Business Mailing Address
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Address Line | 1324 CLARKSON CLAYTON CTR STE 301
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City | ELLISVILLE
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State | MO
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Zip | 63011-2145
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Country | US
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Telephone | 314-541-6838
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Fax |
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Authorized Official
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Title or Position | DESIGNATED OFFICIAL
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Name | KATHLEEN BURK
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Credential |
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Telephone | 314-541-6838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number |
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License Number State |
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