MEDICARE: ENTLC, PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	0478	KY
2	237700000X	Hearing Instrument Specialist	0946	KY
3	363LF0000X	Family Nurse Practitioner	6223P	KY
4	207Y00000X	Otolaryngology Physician	35183	KY

General Provider Information

NPI Number	:	1124217765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTLC, PSC

Provider Business Mailing Address
First Line	:	491 TUCKER DRIVE
Second Line	:
City	:	MAYSVILLE
State	:	KY
Zip	:	41056-9111
Country	:	US
Telephone Number	:	606-759-4852
Fax Number	:	606-759-0112

Provider Business Practice Location Address
First Line	:	491 TUCKER DR
Second Line	:
City	:	MAYSVILLE
State	:	KY
Zip	:	41056-9111
Country	:	US
Telephone Number	:	606-759-4852
Fax Number	:	606-759-0112

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL A CONRAD
Credential	:	M.D., F.A.C.S.
Telephone Number	:	606-759-4852

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	06/13/2013

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Directions to “ENTLC, PSC ” Practice Location

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