Basic Information
Provider Information | |||||||||
NPI: | 1508185075 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UDOFF | ||||||||
FirstName: | ROSS | ||||||||
MiddleName: | ADAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6035 FAIRVIEW RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282103256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042953000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1632 E ROOSEVELT BLVD | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | NC | ||||||||
PostalCode: | 281124017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042953725 | ||||||||
FaxNumber: | 7042953737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2010 | ||||||||
LastUpdateDate: | 04/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 390200000X | NC | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | P01613575 | 01 | NC | MEDICARE RAILROAD | OTHER | 9995479 | 01 |   | AETNA/COVENTRY | OTHER | NC2366 | 05 | SC |   | MEDICAID | 19EUH | 01 | NC | BCBSNC | OTHER |