Provider Demographics
NPI:1972516599
Name:LAWRENCE OTOLARYNGOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:LAWRENCE OTOLARYNGOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-841-1107
Mailing Address - Street 1:1112 W 6TH ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2215
Mailing Address - Country:US
Mailing Address - Phone:785-841-1107
Mailing Address - Fax:785-841-1173
Practice Address - Street 1:1112 W 6TH ST
Practice Address - Street 2:SUITE 216
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2215
Practice Address - Country:US
Practice Address - Phone:785-841-1107
Practice Address - Fax:785-841-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100215660AMedicaid
KS016677Medicare ID - Type Unspecified
KS16677Medicare PIN