Basic Information
| Provider Information | |||||||||
| NPI: | 1558592188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENT CAROLINA PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 ABERDEEN BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048688400 | ||||||||
| FaxNumber: | 7048688493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 SPRUCE ST | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | BELMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280123385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046716380 | ||||||||
| FaxNumber: | 7046716386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVY | ||||||||
| AuthorizedOfficialFirstName: | FREDERIC | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7048688400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890171M | 05 | NC | MEDICAID |