Provider Demographics
NPI:1902043185
Name:EAR NOSE THROAT AND AUDIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:EAR NOSE THROAT AND AUDIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-544-6533
Mailing Address - Street 1:8318 PINEVILLE MATTHEWS RD
Mailing Address - Street 2:SUITE 708-151
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4753
Mailing Address - Country:US
Mailing Address - Phone:704-544-6533
Mailing Address - Fax:704-544-6583
Practice Address - Street 1:327 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-2838
Practice Address - Country:US
Practice Address - Phone:864-429-0115
Practice Address - Fax:864-429-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4146Medicaid
SCGP4146Medicaid