Provider Demographics
NPI:1144295551
Name:JOHNS CREEK ENT PC
Entity type:Organization
Organization Name:JOHNS CREEK ENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:FERMIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-495-7116
Mailing Address - Street 1:4045 JOHNS CREEK PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1253
Mailing Address - Country:US
Mailing Address - Phone:770-495-7116
Mailing Address - Fax:
Practice Address - Street 1:4045 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1253
Practice Address - Country:US
Practice Address - Phone:770-495-7116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042452207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherUNICARE
GA=========OtherBEECHSTREET
GA=========OtherHUMANA
GA=========OtherTRICARE
GA=========OtherCIGNA
GA=========OtherBCBS
GA=========OtherONE HEALTH PLAN
GA=========OtherCOVENTRY
GA=========OtherPHCS
GA=========OtherUNITED HEALTHCARE
GA=========OtherFIRST HEALTH
GA=========OtherGEORGIA 1ST
GA=========OtherBCBS
GA04BDCHMMedicare ID - Type Unspecified