Basic Information
| Provider Information | |||||||||
| NPI: | 1174183156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEEN CITY EAR NOSE AND THROAT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8924 BLAKENEY PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282776660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047031080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8924 BLAKENEY PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282776660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049965353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2019 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DARON | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7047031080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1174183156 | 01 | NC | NATIONAL PROVIDER IDENTIFIER | OTHER |