Provider Demographics
NPI:1164487708
Name:DECATUR ENT ASSOCIATES P C
Entity type:Organization
Organization Name:DECATUR ENT ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:SHONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-355-6200
Mailing Address - Street 1:1218 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4307
Mailing Address - Country:US
Mailing Address - Phone:256-355-6200
Mailing Address - Fax:256-355-6241
Practice Address - Street 1:1218 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4307
Practice Address - Country:US
Practice Address - Phone:256-355-6200
Practice Address - Fax:256-355-6241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD380OtherBCBS OF AL GROUP#
AL529001940Medicaid
ALCM6320OtherRAILROAD MEDICARE
AL529001940Medicaid