Provider Demographics
NPI:1043255540
Name:ENT R NET, P A
Entity type:Organization
Organization Name:ENT R NET, P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-879-0060
Mailing Address - Street 1:4190 CITY AVE
Mailing Address - Street 2:SUITE 526
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-879-0060
Mailing Address - Fax:215-879-0063
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:SUITE 526
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-879-0060
Practice Address - Fax:215-879-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS001941L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0170250000OtherINDEPENDENCE BLUE CROSS
PA183919OtherHIGHMARK BLUE SHIELD
PA30723OtherKEYSTONE MERCY
PA0170250000OtherINDEPENDENCE BLUE CROSS