Basic Information
| Provider Information | |||||||||
| NPI: | 1235247933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA EAR, NOSE & THROAT HEAD AND NECK SURGERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 256C 10TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286013832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283222183 | ||||||||
| FaxNumber: | 8283284526 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 MULBERRY ST SW | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LENOIR | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286455463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287542464 | ||||||||
| FaxNumber: | 8287590894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRILL | ||||||||
| AuthorizedOfficialFirstName: | WILLARD | ||||||||
| AuthorizedOfficialMiddleName: | CARDWELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8283222183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0298Q | 01 | NC | BCBS | OTHER | 890298Q | 05 | NC | MEDICAID |