Provider Demographics
NPI:1528423068
Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Entity type:Organization
Organization Name:CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAG
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:SCD
Authorized Official - Phone:704-295-3000
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:149 PLANTATION RIDGE DRIVE
Practice Address - Street 2:SUITE 190
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9178
Practice Address - Country:US
Practice Address - Phone:704-658-0595
Practice Address - Fax:704-658-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty