Provider Demographics
NPI:1710932629
Name:WILMINGTON EAR NOSE & THROAT ASSOC., P.A.
Entity Type:Organization
Organization Name:WILMINGTON EAR NOSE & THROAT ASSOC., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-762-8754
Mailing Address - Street 1:2311 DELANEY RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6012
Mailing Address - Country:US
Mailing Address - Phone:910-762-8754
Mailing Address - Fax:910-762-0778
Practice Address - Street 1:2311 DELANEY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6012
Practice Address - Country:US
Practice Address - Phone:910-762-8754
Practice Address - Fax:910-762-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01157OtherBLUE CROSS GROUP NUMBER
NC5902912Medicaid
NCCD6751OtherRAIL ROAD MEDICARE
NC8901157Medicaid
NC3404217Medicaid
NC8901157Medicaid