Healthcare Provider Details

I. General information

NPI: 1174814438
Provider Name (Legal Business Name): CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 NE GATEWAY CT NE SUITE 100
CONCORD NC
28025-2406
US

IV. Provider business mailing address

6035 FAIRVIEW RD
CHARLOTTE NC
28210-3256
US

V. Phone/Fax

Practice location:
  • Phone: 704-782-2166
  • Fax: 704-782-2533
Mailing address:
  • Phone: 704-295-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name: JAG S GILL
Title or Position: CEO/ADMINISTRATOR
Credential: SCD
Phone: 704-295-3366