Provider Demographics
NPI:1316167463
Name:EAR NOSE AND THROAT SPECIALISTS OF WEST CENTRAL OHIO
Entity type:Organization
Organization Name:EAR NOSE AND THROAT SPECIALISTS OF WEST CENTRAL OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-227-9500
Mailing Address - Street 1:770 WEST HIGH ST
Mailing Address - Street 2:SUITE 480
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801
Mailing Address - Country:US
Mailing Address - Phone:419-227-9500
Mailing Address - Fax:419-227-9503
Practice Address - Street 1:770 WEST HIGH ST
Practice Address - Street 2:SUITE 480
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801
Practice Address - Country:US
Practice Address - Phone:419-227-9500
Practice Address - Fax:419-227-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083245207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35083245OtherLICENSE NUMBER
OH2445705Medicaid
OH2445705Medicaid
DA4116521Medicare ID - Type Unspecified
OH2445705Medicaid