Provider Demographics
NPI:1548444938
Name:SOUTHWESTERN VIRGINIA EARS NOSE AND THROAT ASSOCIATES PC
Entity type:Organization
Organization Name:SOUTHWESTERN VIRGINIA EARS NOSE AND THROAT ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRUSSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-381-0344
Mailing Address - Street 1:106 WADSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-1439
Mailing Address - Country:US
Mailing Address - Phone:540-639-9023
Mailing Address - Fax:540-639-5463
Practice Address - Street 1:2955 MARKET ST SUITE C-4
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6575
Practice Address - Country:US
Practice Address - Phone:540-381-0344
Practice Address - Fax:540-381-1462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051964207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE68557Medicare UPIN
VAC06637Medicare PIN