Basic Information
| Provider Information | |||||||||
| NPI: | 1154516201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW ROAD | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7048388494 | ||||||||
| Practice Location | |||||||||
| Address1: | 646 HARTNESS RD | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286773423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7048388494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | GILL | ||||||||
| AuthorizedOfficialFirstName: | JAG | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7042953000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SCD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.