Provider Demographics
NPI:1659578474
Name:FAYETTEVILLE OTOLARYNGOLOGY HEAD AND NECK SURGERY PA
Entity Type:Organization
Organization Name:FAYETTEVILLE OTOLARYNGOLOGY HEAD AND NECK SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-1463
Mailing Address - Street 1:1839 QUIET CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3857
Mailing Address - Country:US
Mailing Address - Phone:910-323-1463
Mailing Address - Fax:910-323-1575
Practice Address - Street 1:1839 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-323-1463
Practice Address - Fax:910-323-1575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty