=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619175882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAR NOSE AND THROAT SPECIALISTS OF FLORIDA PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 01/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 BARKLEY CIR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-7531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-1616
-----------------------------------------------------
Fax | 239-274-3873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 BARKLEY CIR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-7531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-1616
-----------------------------------------------------
Fax | 239-936-0837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. RICHARD J LANE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 239-936-1616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------