Provider Demographics
NPI:1407890361
Name:CAROLINA EAR, NOSE & THROAT HEAD AND NECK SURGERY CENTER, P.A.
Entity Type:Organization
Organization Name:CAROLINA EAR, NOSE & THROAT HEAD AND NECK SURGERY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:CARDWELL
Authorized Official - Last Name:HARRILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-322-2183
Mailing Address - Street 1:114 GATEWAY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5540
Mailing Address - Country:US
Mailing Address - Phone:704-658-0720
Mailing Address - Fax:704-663-0382
Practice Address - Street 1:114 GATEWAY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5540
Practice Address - Country:US
Practice Address - Phone:704-658-0720
Practice Address - Fax:704-663-0382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Y00000X
332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0298QOtherBCBS
NC0298QOtherBCBS