Basic Information
| Provider Information | |||||||||
| NPI: | 1205863479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL CAROLINA ENT ASSOC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 KM WICKER DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746829 | ||||||||
| FaxNumber: | 9197752327 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 KM WICKER DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746829 | ||||||||
| FaxNumber: | 9197752327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | LELIEVER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197746829 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 890107W | 05 | NC | MEDICAID | 3404108 | 01 | NC | MEDICAID - HEARING AID VENDOR | OTHER | CM5921 | 01 | NC | PALMETTO GBA-RR MEDICARE | OTHER |