NPIMap

Organization Active NPI

Decatur ENT Associates P C

  • Facial Plastic Surgery Physician
  • Decatur, AL
National Provider Identifier
1164487708
Registry record updated Feb 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Facial Plastic Surgery PhysicianTaxonomy code 207YS0123X
Legal business name
DECATUR ENT ASSOCIATES P C
Practice address
1218 13TH Ave SE
Decatur, AL 35601-4307
Phone
(256) 355-6200
Fax
(256) 355-6241
NPI assigned
Apr 18, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shondra Clark
Title
Billing/Insurance
Phone
(256) 355-6200

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Facial Plastic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207YS0123X Primary
Otolaryngic Allergy PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207YX0602X

Addresses

Primary practice location

1218 13TH Ave SE
Decatur, AL 35601-4307

Mailing address

1218 13TH Ave SE
Decatur, AL 35601-4307
Phone (256) 355-6200

Other identifiers 3

IdentifierTypeStateIssuer
D380OtherALBCBS OF AL GROUP#
529001940MedicaidAL
CM6320OtherALRAILROAD MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050328000748 AL Part B Supplier - Clinic/Group Practice 2163478629 Receives reassigned benefits from 9 practitioners
Practice locations: Decatur, AL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
01D0676999Decatur ENT Associates1218 13TH Ave SE, Decatur, AL 35601Certificate of waiverJul 27, 2028

National Provider Directory

National Provider Directory

Locations

1218 13th Ave SE
Decatur, AL 35601
Phone (205) 355-6200

4245 Balmoral Dr SW
Huntsville, AL 35801
Phone (256) 885-3749

2649 Huntsville Hwy
Fayetteville, TN 37334
Phone (356) 829-9544

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1145318400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1676851200000",
    "number": "1164487708",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1218 13TH AVE SE",
            "city": "DECATUR",
            "state": "AL",
            "postal_code": "356014307",
            "telephone_number": "256-355-6200",
            "fax_number": "256-355-6241"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1218 13TH AVE SE",
            "city": "DECATUR",
            "state": "AL",
            "postal_code": "356014307",
            "telephone_number": "256-355-6200",
            "fax_number": "256-355-6241"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DECATUR ENT ASSOCIATES P C",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-18",
        "last_updated": "2023-02-20",
        "certification_date": "2023-02-20",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "SHONDRA",
        "authorized_official_title_or_position": "BILLING/INSURANCE",
        "authorized_official_telephone_number": "256-355-6200"
    },
    "taxonomies": [
        {
            "code": "207YS0123X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology, Facial Plastic Surgery",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207YX0602X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology, Otolaryngic Allergy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF AL GROUP#",
            "identifier": "D380",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "529001940",
            "state": "AL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CM6320",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Decatur, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.