Basic Information
| Provider Information | |||||||||
| NPI: | 1669577052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISTWA | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282110035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282110035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 230273 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2008-00220 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00629319 | 01 | NC | RR MEDICARE | OTHER | 1476K | 01 | NC | BCBS | OTHER | N20008 | 05 | SC | MEDICAID | 59-08628 | 05 | NC | MEDICAID |