Provider Demographics
NPI:1528496734
Name:CENTRAL PARK EAR NOSE AND THROAT, LLP FORT WORTH
Entity type:Organization
Organization Name:CENTRAL PARK EAR NOSE AND THROAT, LLP FORT WORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O./ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:JD, CPA, MBA
Authorized Official - Phone:817-261-9191
Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:SUITE 618
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2601
Mailing Address - Country:US
Mailing Address - Phone:817-335-3366
Mailing Address - Fax:
Practice Address - Street 1:409 CENTRAL PARK DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2069
Practice Address - Country:US
Practice Address - Phone:817-261-9191
Practice Address - Fax:817-784-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty