Provider Demographics
NPI:1588025381
Name:SALEM PEDIATRIC EAR AND AIRWAY CENTER, PLLC
Entity Type:Organization
Organization Name:SALEM PEDIATRIC EAR AND AIRWAY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADELE
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-699-2269
Mailing Address - Street 1:615 SAINT GEORGE SQUARE CT
Mailing Address - Street 2:SUITE 364
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1356
Mailing Address - Country:US
Mailing Address - Phone:336-245-4972
Mailing Address - Fax:336-450-1676
Practice Address - Street 1:615 SAINT GEORGE SQUARE CT
Practice Address - Street 2:SUITE 364
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1356
Practice Address - Country:US
Practice Address - Phone:336-245-4972
Practice Address - Fax:336-450-1676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00303207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1760414866Medicaid