Provider Demographics
NPI:1104911288
Name:EAR NOSE & THROAT & PLASTIC SURG INC
Entity type:Organization
Organization Name:EAR NOSE & THROAT & PLASTIC SURG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:314-821-5002
Mailing Address - Street 1:2315 DOUGHERTY FERRY ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122
Mailing Address - Country:US
Mailing Address - Phone:314-821-5002
Mailing Address - Fax:314-821-5029
Practice Address - Street 1:2315 DOUGHERTY FERRY ROAD
Practice Address - Street 2:STE. 103
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122
Practice Address - Country:US
Practice Address - Phone:314-821-5002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO040010750OtherMEDICARE RAILROAD
MOCP2222OtherMEDICARE RAILROAD
MO040017959OtherMEDICARE RAILROAD
MO040003579OtherMEDICARE RAILROAD
MO502754401Medicaid
MO040017959OtherMEDICARE RAILROAD