Provider Demographics
NPI:1558592188
Name:ENT CAROLINA PA
Entity Type:Organization
Organization Name:ENT CAROLINA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-868-8400
Mailing Address - Street 1:2520 ABERDEEN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0635
Mailing Address - Country:US
Mailing Address - Phone:704-868-8400
Mailing Address - Fax:704-868-8493
Practice Address - Street 1:1212 SPRUCE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3385
Practice Address - Country:US
Practice Address - Phone:704-671-6380
Practice Address - Fax:704-671-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890171MMedicaid