Basic Information
| Provider Information | |||||||||
| NPI: | 1114905148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EAR NOSE AND THROAT SURGICAL ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 01/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEHMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4076444883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | C31310 | 01 | RR MEDICARE | OTHER | CB0799 | 01 | RR MEDICARE | OTHER | 24437 | 01 | BC/BS GROUP NUMBER | OTHER | 375028100 | 05 | FL | MEDICAID | CB0800 | 01 | RR MEDICARE | OTHER |