Healthcare Provider Details

I. General information

NPI: 1003060757
Provider Name (Legal Business Name): EASTERN ENT SINUS & ALLERGY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 BALSEY ST
CLINTON NC
28328-2902
US

IV. Provider business mailing address

2707 MEDICAL OFFICE PL
GOLDSBORO NC
27534-9458
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-9993
  • Fax: 910-593-9994
Mailing address:
  • Phone: 919-735-9146
  • Fax: 919-735-0582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number28594
License Number StateNC

VIII. Authorized Official

Name: DANIEL WHITLEY JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 919-735-9146