Basic Information
| Provider Information | |||||||||
| NPI: | 1295255255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE WATER EAR NOSE AND THROAT, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4917 S CROATAN HWY STE 1C | ||||||||
| Address2: | |||||||||
| City: | NAGS HEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279598996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524894682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4917 S CROATAN HWY STE 1C | ||||||||
| Address2: | |||||||||
| City: | NAGS HEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279598996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524894682 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAIT | ||||||||
| AuthorizedOfficialFirstName: | MARCI | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2524894682 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.