=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578747408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST OTOLARYNGOLOGY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 10/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12255 DE PAUL DR STE 830N
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-291-5307
-----------------------------------------------------
Fax | 314-291-0838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12255 DE PAUL DR STE 830N
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-291-5307
-----------------------------------------------------
Fax | 314-291-0838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MELISSA BUDZINSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 636-379-6006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------