Provider Demographics
NPI:1164554606
Name:LAURINBURG ENT CLINIC PA
Entity Type:Organization
Organization Name:LAURINBURG ENT CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-610-4368
Mailing Address - Street 1:1705 BERWICK DR # B
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-5523
Mailing Address - Country:US
Mailing Address - Phone:910-610-4368
Mailing Address - Fax:910-610-4388
Practice Address - Street 1:1705 BERWICK DR # B
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5523
Practice Address - Country:US
Practice Address - Phone:910-610-4368
Practice Address - Fax:910-610-4388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400093207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890123JMedicaid
NC2210991Medicare PIN