Provider Demographics
NPI:1366632655
Name:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-328-3686
Mailing Address - Street 1:8334 PINEVILLE MATTHEWS RD
Mailing Address - Street 2:SUITE 103-151
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3774
Mailing Address - Country:US
Mailing Address - Phone:803-328-3686
Mailing Address - Fax:803-328-9889
Practice Address - Street 1:744 ARDEN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2984
Practice Address - Country:US
Practice Address - Phone:803-328-3686
Practice Address - Fax:803-328-9889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAR NOSE THROAT & AUDIOLOGY ASSOCIATES OF THE CAROLINAS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-01
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
SCGP4146Medicaid
SCGP4146Medicaid