Healthcare Provider Details

I. General information

NPI: 1073599734
Provider Name (Legal Business Name): SURGICAL SPECIALISTS OF CHARLOTTE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 CARMEL EXECUTIVE PARK DR STE 200
CHARLOTTE NC
28226-1336
US

IV. Provider business mailing address

PO BOX 33369
CHARLOTTE NC
28233-3369
US

V. Phone/Fax

Practice location:
  • Phone: 704-916-2108
  • Fax: 704-365-2073
Mailing address:
  • Phone: 704-333-0741
  • Fax: 704-365-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number38870
License Number StateNC

VIII. Authorized Official

Name: LESLIE T. WEBSTER III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-364-8100