Healthcare Provider Details

I. General information

NPI: 1467469320
Provider Name (Legal Business Name): KENT SEITZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 ORCHARD LAKE DRIVE SUITE C
CHARLOTTE NC
28270
US

IV. Provider business mailing address

1421 ORCHARD LAKE DRIVE SUITE C
CHARLOTTE NC
28270
US

V. Phone/Fax

Practice location:
  • Phone: 704-844-0181
  • Fax: 904-701-6279
Mailing address:
  • Phone: 704-844-0181
  • Fax: 904-701-6279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberME0051124
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2009-00067
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2009-00067
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: