Basic Information
| Provider Information | |||||||||
| NPI: | 1407806110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENTWISTLE | ||||||||
| FirstName: | CELIA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046389990 | ||||||||
| FaxNumber: | 7046390785 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280250939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047861108 | ||||||||
| FaxNumber: | 7047821826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 36179 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083P0011X | 36179 | NC | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 046910802 | 05 | TX | MEDICAID | 89-30701 | 05 | NC | MEDICAID | 30701 | 01 | NC | BCBSNC | OTHER | 930095201 | 01 | NC | RR MEDICARE | OTHER | N36179 | 05 | SC | MEDICAID |