Provider Demographics
NPI:1093769069
Name:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES OF THE CAROLINAS, P.A.
Entity Type:Organization
Organization Name:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES OF THE CAROLINAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-544-6533
Mailing Address - Street 1:8334 PINEVILLE MATTHEWS RD
Mailing Address - Street 2:STE 103151
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3774
Mailing Address - Country:US
Mailing Address - Phone:704-544-6533
Mailing Address - Fax:704-544-6583
Practice Address - Street 1:7006 SHANNON WILLOW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1318
Practice Address - Country:US
Practice Address - Phone:704-544-6533
Practice Address - Fax:704-544-6583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-22
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134F5Medicaid
NC2334237Medicare ID - Type Unspecified