Provider Demographics
NPI:1003060757
Name:EASTERN ENT SINUS & ALLERGY CENTER, PA
Entity Type:Organization
Organization Name:EASTERN ENT SINUS & ALLERGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:919-735-9146
Mailing Address - Street 1:2707 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9458
Mailing Address - Country:US
Mailing Address - Phone:919-735-9146
Mailing Address - Fax:919-735-0582
Practice Address - Street 1:504 BALSEY ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2902
Practice Address - Country:US
Practice Address - Phone:910-592-9993
Practice Address - Fax:910-593-9994
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN ENT SINUS & ALLERGY CENTER, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-07
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0460110002Medicare NSC