# IMAGE, EAR, NOSE & THROAT SURGERY, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1689992398
- **Authorized official:** KEITH A. BONACQUISTI MD (PRESIDENT)
- **Authorized official phone:** (636) 937-2388

## Contact information

- **Practice address:** 1151 GANNON DRIVE EAST, FESTUS, MO 63028-2611
- **Practice address phone:** (636) 937-2388
- **Practice address fax:** (636) 937-4976
- **Mailing address:** 1151 GANNON DRIVE EAST, FESTUS, MO 63028-2611
- **Mailing address phone:** (636) 937-2388
- **Mailing address fax:** (636) 937-4976

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Y00000X | Otolaryngology Physician | 109503 | MO | Yes |

## Other

- **Enumeration date:** 05/06/2010
- **Last updated:** 05/14/2010