Provider Demographics
NPI:1609019363
Name:OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A.
Entity type:Organization
Organization Name:OTOLARYNGOLOGY HEAD & NECK SURGERY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENUSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-702-0750
Mailing Address - Street 1:215 RADIO DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-5822
Mailing Address - Country:US
Mailing Address - Phone:651-702-0750
Mailing Address - Fax:651-645-6166
Practice Address - Street 1:217 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5805
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:651-645-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1821195959Medicaid
MN1821195959OtherMEDICARE PTAN C00273