Provider Demographics
NPI:1073599734
Name:SURGICAL SPECIALISTS OF CHARLOTTE, P.A.
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF CHARLOTTE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:704-364-8100
Mailing Address - Street 1:PO BOX 33369
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28233-3369
Mailing Address - Country:US
Mailing Address - Phone:704-333-0741
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:7300 CARMEL EXECUTIVE PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1336
Practice Address - Country:US
Practice Address - Phone:704-916-2108
Practice Address - Fax:704-365-2073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38870208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901293Medicaid
NC230237Medicare PIN