Provider Demographics
NPI:1366484958
Name:GENESIS ENT & PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:GENESIS ENT & PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-544-1300
Mailing Address - Street 1:14835 JOHN J DELANEY DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2738
Mailing Address - Country:US
Mailing Address - Phone:704-544-1300
Mailing Address - Fax:704-544-2765
Practice Address - Street 1:14835 JOHN J DELANEY DR
Practice Address - Street 2:SUITE 210
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2738
Practice Address - Country:US
Practice Address - Phone:704-544-1300
Practice Address - Fax:704-544-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700531207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC191722Medicaid
NC191722Medicaid