Provider Demographics
NPI:1407806110
Name:ENTWISTLE, CELIA B (MD)
Entity Type:Individual
Prefix:
First Name:CELIA
Middle Name:B
Last Name:ENTWISTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-638-9990
Mailing Address - Fax:704-639-0785
Practice Address - Street 1:200 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0939
Practice Address - Country:US
Practice Address - Phone:704-786-1108
Practice Address - Fax:704-782-1826
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36179207P00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046910802Medicaid
NC89-30701Medicaid
NC30701OtherBCBSNC
NC930095201OtherRR MEDICARE
SCN36179Medicaid
E58259Medicare UPIN
TX322151YKN5Medicare PIN
NC89-30701Medicaid