Healthcare Provider Details

I. General information

NPI: 1093769069
Provider Name (Legal Business Name): EAR NOSE THROAT & AUDIOLOGY ASSOCIATES OF THE CAROLINAS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7006 SHANNON WILLOW RD
CHARLOTTE NC
28226-1318
US

IV. Provider business mailing address

8334 PINEVILLE MATTHEWS RD STE 103151
CHARLOTTE NC
28226-3774
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-6533
  • Fax: 704-544-6583
Mailing address:
  • Phone: 704-544-6533
  • Fax: 704-544-6583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: LEROY BROADNAX
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-544-6533