Provider Demographics
NPI:1386374593
Name:PRIMARY ENT, L.L.C.
Entity type:Organization
Organization Name:PRIMARY ENT, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-406-9966
Mailing Address - Street 1:6021 NORTHWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1282
Mailing Address - Country:US
Mailing Address - Phone:612-406-9966
Mailing Address - Fax:
Practice Address - Street 1:14020 HWY 13 S STE 350
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-7103
Practice Address - Country:US
Practice Address - Phone:952-395-2500
Practice Address - Fax:952-395-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1609035781Medicaid