Healthcare Provider Details

I. General information

NPI: 1366484958
Provider Name (Legal Business Name): GENESIS ENT & PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14835 JOHN J DELANEY DR SUITE 210
CHARLOTTE NC
28277-2738
US

IV. Provider business mailing address

14835 JOHN J DELANEY DR SUITE 210
CHARLOTTE NC
28277-2738
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-1300
  • Fax: 704-544-2765
Mailing address:
  • Phone: 704-544-1300
  • Fax: 704-544-2765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number9700531
License Number StateNC

VIII. Authorized Official

Name: HENRY FORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-544-1300