MEDICARE: EAR NOSE & THROAT ASSC OF CHARL INC

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	207Y00000X	Otolaryngology Physician		WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CA7089	OTHER	WV	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0778148001	OTHER	WV	CIGNA

General Provider Information

NPI Number	:	1295735850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAR NOSE & THROAT ASSC OF CHARL INC

Provider Business Mailing Address
First Line	:	PO BOX 1628
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25326-1628
Country	:	US
Telephone Number	:	304-340-2225
Fax Number	:	304-340-2204

Provider Business Practice Location Address
First Line	:	500 DONNALLY ST
Second Line	:	SUITE 200
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1648
Country	:	US
Telephone Number	:	304-342-0124
Fax Number	:	304-340-2204

Authorized Official
Title or Position	:	PHYSICIAN DIRECTOR
Name	:	MR. FREDERICK THOMAS SPORCK
Credential	:	MD
Telephone Number	:	304-340-2225

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/21/2022

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Directions to “EAR NOSE & THROAT ASSC OF CHARL INC ” Practice Location

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