Provider Demographics
NPI:1598822280
Name:ENT OF ATHENS, LLC
Entity type:Organization
Organization Name:ENT OF ATHENS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-546-7908
Mailing Address - Street 1:150 NACOOCHEE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1823
Mailing Address - Country:US
Mailing Address - Phone:706-546-7908
Mailing Address - Fax:706-546-0918
Practice Address - Street 1:150 NACOOCHEE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1823
Practice Address - Country:US
Practice Address - Phone:706-546-7908
Practice Address - Fax:706-546-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12368207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581440304OtherINDIVIDUAL TAX ID
GA581198425OtherINDIVIDUAL TAX ID
GA000135902AMedicaid
GA000135924AMedicaid
GAD30796Medicare UPIN
GAE58124Medicare UPIN
GA427967818BMedicare ID - Type Unspecified
GA000135902AMedicaid