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General NPI Number Information
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NPI Number | 1689992398
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Entity Type | Organization
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Legal Business Name | IMAGE, EAR, NOSE & THROAT SURGERY, INC.
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Dates
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Enumeration Date | 05/06/2010
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Last Update Date | 05/14/2010
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Provider Practice Location Address
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Address Line | 1151 GANNON DRIVE EAST
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City | FESTUS
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State | MO
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Zip | 63028-2611
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Country | US
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Telephone | 636-937-2388
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Fax | 636-937-4976
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Provider Business Mailing Address
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Address Line | 1151 GANNON DRIVE EAST
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City | FESTUS
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State | MO
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Zip | 63028-2611
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Country | US
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Telephone | 636-937-2388
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Fax | 636-937-4976
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEITH A. BONACQUISTI
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Credential | MD
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Telephone | 636-937-2388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 109503
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License Number State | MO
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