Basic Information
| Provider Information | |||||||||
| NPI: | 1922033448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA ENT SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1085 NE GATEWAY CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047822166 | ||||||||
| FaxNumber: | 7047822533 | ||||||||
| Practice Location | |||||||||
| Address1: | 1085 NE GATEWAY CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047822166 | ||||||||
| FaxNumber: | 7047822533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | CHIKES | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7047822166 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 231H00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 207Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 890112H | 05 | NC | MEDICAID |