Provider Demographics
NPI:1003993254
Name:NORTH FLORIDA REGIONAL OTOLARYNGOLOGY, LLC
Entity type:Organization
Organization Name:NORTH FLORIDA REGIONAL OTOLARYNGOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APM
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-333-5961
Mailing Address - Street 1:6400 W NEWBERRY RD
Mailing Address - Street 2:SUITE 101 MAB
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-6605
Mailing Address - Country:US
Mailing Address - Phone:352-333-5961
Mailing Address - Fax:
Practice Address - Street 1:6400 W NEWBERRY RD
Practice Address - Street 2:SUITE 101 MAB
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-6605
Practice Address - Country:US
Practice Address - Phone:352-333-5961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA016Medicare PIN