Provider Demographics
NPI:1588607303
Name:CHARLESTON ENT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CHARLESTON ENT ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MBA
Authorized Official - Phone:843-766-7103
Mailing Address - Street 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-6103
Mailing Address - Fax:843-576-2592
Practice Address - Street 1:2295 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7801
Practice Address - Country:US
Practice Address - Phone:843-766-6103
Practice Address - Fax:843-576-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1728Medicaid
SC5449Medicare PIN