Provider Demographics
NPI:1861432171
Name:WACO OTOLARYNGOLOGY ASSOCIATES
Entity type:Organization
Organization Name:WACO OTOLARYNGOLOGY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEADMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-776-7744
Mailing Address - Street 1:601 W HIGHWAY 6
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5575
Mailing Address - Country:US
Mailing Address - Phone:254-776-7744
Mailing Address - Fax:254-751-9211
Practice Address - Street 1:601 W HIGHWAY 6
Practice Address - Street 2:SUITE 106
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5575
Practice Address - Country:US
Practice Address - Phone:254-776-7744
Practice Address - Fax:254-751-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCD9784Medicare PIN
TX00AC30Medicare ID - Type UnspecifiedMEDICARE GROUP#
TX0940900001Medicare NSC