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General NPI Number Information
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NPI Number | 1417958786
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Entity Type | Organization
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Legal Business Name | THOMASTON EAR, NOSE AND THROAT INC.
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Dates
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Enumeration Date | 08/09/2005
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Last Update Date | 04/17/2008
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Provider Practice Location Address
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Address Line | 210 CHEROKEE RD
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City | THOMASTON
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State | GA
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Zip | 30286-3402
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Country | US
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Telephone | 706-646-4508
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Fax | 706-646-2752
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Provider Business Mailing Address
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Address Line | 210 CHEROKEE RD
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City | THOMASTON
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State | GA
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Zip | 30286-3402
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Country | US
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Telephone | 706-646-4508
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Fax | 706-646-2752
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Authorized Official
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Title or Position | PHYSICIAN/PRESIDENT
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Name | DR. KEVIN ANTHONY O'CONNELL
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Credential | MD
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Telephone | 706-646-4508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 041918
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License Number State | GA
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