Provider Demographics
NPI:1992082226
Name:ADVANCED OTOLARYNGOLOGY & ALLERGY LLC
Entity type:Organization
Organization Name:ADVANCED OTOLARYNGOLOGY & ALLERGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:EICHELBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-632-2221
Mailing Address - Street 1:864 BROADWAY STE 101
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1501
Mailing Address - Country:US
Mailing Address - Phone:717-632-2221
Mailing Address - Fax:717-965-7519
Practice Address - Street 1:864 BROADWAY STE 101
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1501
Practice Address - Country:US
Practice Address - Phone:717-632-2221
Practice Address - Fax:717-965-7519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207NS0135X, 261QH0700X, 261QM1300X, 261QU0200X, 332S00000X
PAMD432200207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11782821OtherCAQH
PAMD432200OtherLICENSE