MEDICARE: FAYETTEVILLE-SPRINGDALE EAR, NOSE & THROAT CLINIC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1841408788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE-SPRINGDALE EAR, NOSE & THROAT CLINIC

Provider Business Mailing Address
First Line	:	4255 N VENETIAN LN
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-5077
Country	:	US
Telephone Number	:	479-521-1238
Fax Number	:	479-521-0509

Provider Business Practice Location Address
First Line	:	4255 N VENETIAN LN
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-5077
Country	:	US
Telephone Number	:	479-521-1238
Fax Number	:	479-521-0509

Authorized Official
Title or Position	:	OWNER
Name	:	RANDALL DAVIS
Credential	:	MD
Telephone Number	:	479-521-1238

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	06/18/2008

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