MEDICARE: ADVANCED EAR, NOSE, THROAT ASSOCIATES, LLC

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	ME104096	FL

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

General Provider Information

NPI Number	:	1861791402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED EAR, NOSE, THROAT ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1560 ROBERTS DR
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3222
Country	:	US
Telephone Number	:	904-339-0350
Fax Number	:	904-339-0351

Provider Business Practice Location Address
First Line	:	1560 ROBERTS DR
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3222
Country	:	US
Telephone Number	:	904-339-0350
Fax Number	:	904-339-0351

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KUNAL THAKKAR
Credential	:	MD
Telephone Number	:	904-339-0350

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	12/06/2018

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