Provider Demographics
NPI:1528102498
Name:PEDIATRIC EAR, NOSE & THROAT SPECIALISTS SC
Entity type:Organization
Organization Name:PEDIATRIC EAR, NOSE & THROAT SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BESTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-266-2761
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 265
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3518
Mailing Address - Country:US
Mailing Address - Phone:414-266-2761
Mailing Address - Fax:414-266-2766
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:SUITE 265
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3518
Practice Address - Country:US
Practice Address - Phone:414-266-2761
Practice Address - Fax:414-266-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43113207YP0228X
WI22968207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30581400Medicaid
WI34060600Medicaid
WI30581400Medicaid
WI73666Medicare ID - Type Unspecified
WI34060600Medicaid