Provider Demographics
NPI:1124105671
Name:SHOALS EAR NOSE & THROAT GROUP PC
Entity type:Organization
Organization Name:SHOALS EAR NOSE & THROAT GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-386-7040
Mailing Address - Street 1:421 COX BLVD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660
Mailing Address - Country:US
Mailing Address - Phone:256-386-7040
Mailing Address - Fax:256-383-7808
Practice Address - Street 1:421 COX BLVD
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660
Practice Address - Country:US
Practice Address - Phone:256-386-7040
Practice Address - Fax:256-383-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10880207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51011662OtherBCBS AL
C71241Medicare UPIN
I036Medicare ID - Type Unspecified