Basic Information
| Provider Information | |||||||||
| NPI: | 1952372237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENSBORO EAR NOSE & THROAT ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1132 N CHURCH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363584268 | ||||||||
| FaxNumber: | 3365447180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1132 N CHURCH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363584268 | ||||||||
| FaxNumber: | 3365447180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 07/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROSEN | ||||||||
| AuthorizedOfficialFirstName: | JEFRY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3363584268 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 39952 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 01993 | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER | CD4175 | 01 | NC | RAILROAD MEDICARE | OTHER | 7001505 | 05 | NC | MEDICAID | 8901993 | 05 | NC | MEDICAID |