Provider Demographics
NPI:1801217948
Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Entity Type:Organization
Organization Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAG
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:SCD
Authorized Official - Phone:704-295-3000
Mailing Address - Street 1:530 CORPORATE CIR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-8074
Mailing Address - Country:US
Mailing Address - Phone:704-637-0158
Mailing Address - Fax:704-637-7710
Practice Address - Street 1:530 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-8074
Practice Address - Country:US
Practice Address - Phone:704-637-0158
Practice Address - Fax:704-637-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0264730015Medicare NSC