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General NPI Number Information
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NPI Number | 1821200080
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN OHIO OTOLARYNGOLOGY, INC.
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 01/09/2014
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Provider Practice Location Address
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Address Line | 930 BETHESDA DR. BLDG 4
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City | ZANESVILLE
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State | OH
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Zip | 43701-0815
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Country | US
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Telephone | 740-455-6202
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Fax |
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Provider Business Mailing Address
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Address Line | 930 BETHESDA DR. BLDG 4
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City | ZANESVILLE
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State | OH
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Zip | 43701-0815
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Country | US
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Telephone | 740-455-6202
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK B BOOTH
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Credential | M.D.
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Telephone | 740-455-6202
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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 |
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License Number State |
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