Basic Information
| Provider Information | |||||||||
| NPI: | 1306950530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDCAROLINA ENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALBEMARLE ENT | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1908 HILCO ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280016387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049835350 | ||||||||
| FaxNumber: | 7049835370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1908 HILCO ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280016387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049835350 | ||||||||
| FaxNumber: | 7049835370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EMERY | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7049835350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 89014V0 | 05 | NC | MEDICAID |