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General NPI Number Information
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NPI Number | 1831225465
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Entity Type | Organization
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Legal Business Name | JACKSON ENT CLINIC , PSC
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 11/14/2008
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Provider Practice Location Address
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Address Line | 1550 HIGHWAY 15 S STE 29
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City | JACKSON
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State | KY
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Zip | 41339-9221
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Country | US
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Telephone | 606-666-9909
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Fax | 606-666-9982
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Provider Business Mailing Address
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Address Line | PO BOX 768
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City | JACKSON
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State | KY
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Zip | 41339-0768
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Country | US
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Telephone | 606-666-9909
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Fax | 606-666-9982
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Authorized Official
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Title or Position | OWNER
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Name | DR. TARIQ A SARTAWI
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Credential | M.D.
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Telephone | 606-666-9909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 36227
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 36227
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License Number State | KY
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