Provider Demographics
NPI:1861583700
Name:NORTH CAROLINA EYE EAR NOSE & THROAT PA
Entity type:Organization
Organization Name:NORTH CAROLINA EYE EAR NOSE & THROAT PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-595-2143
Mailing Address - Street 1:4102 N ROXBORO ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2122
Mailing Address - Country:US
Mailing Address - Phone:919-595-2000
Mailing Address - Fax:919-595-2143
Practice Address - Street 1:911 RIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4574
Practice Address - Country:US
Practice Address - Phone:336-597-2826
Practice Address - Fax:336-597-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0344620007Medicare ID - Type UnspecifiedPALMETTO GBA - DEMERC