Provider Demographics
NPI:1225113848
Name:NORTHWEST EAR NOSE & THROAT, PA
Entity Type:Organization
Organization Name:NORTHWEST EAR NOSE & THROAT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-526-1977
Mailing Address - Street 1:250 JOHNSON RIDGE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2443
Mailing Address - Country:US
Mailing Address - Phone:336-526-1977
Mailing Address - Fax:336-526-0061
Practice Address - Street 1:250 JOHNSON RIDGE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2443
Practice Address - Country:US
Practice Address - Phone:336-526-1977
Practice Address - Fax:336-526-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74908261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890264PMedicaid
NC890264PMedicaid