Provider Demographics
NPI:1821179037
Name:GREATER CAROLINA EAR NOSE &THROAT P.A.
Entity Type:Organization
Organization Name:GREATER CAROLINA EAR NOSE &THROAT P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:910-738-1919
Mailing Address - Street 1:4315 LUDGATE STREET
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2460
Mailing Address - Country:US
Mailing Address - Phone:910-738-1919
Mailing Address - Fax:910-738-1991
Practice Address - Street 1:4315 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2460
Practice Address - Country:US
Practice Address - Phone:910-738-1919
Practice Address - Fax:910-738-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0215YOtherBCBS
NC890215YMedicaid
NCDQ4495OtherRAILROAD MEDICARE
NC103883OtherUNITEDHEALTHCARE
NC890215YMedicaid