Provider Demographics
NPI:1457483273
Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Entity Type:Organization
Organization Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAG
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:SCD
Authorized Official - Phone:704-295-3000
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:704-295-3468
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:704-295-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013JPOtherBCBS