Healthcare Provider Details

I. General information

NPI: 1225113848
Provider Name (Legal Business Name): NORTHWEST EAR NOSE & THROAT, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

IV. Provider business mailing address

250 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

V. Phone/Fax

Practice location:
  • Phone: 336-526-1977
  • Fax: 336-526-0061
Mailing address:
  • Phone: 336-526-1977
  • Fax: 336-526-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number74908
License Number StateNC

VIII. Authorized Official

Name: MRS. DONNA S CHEEK
Title or Position: PRACTICE MANAGER
Credential:
Phone: 336-526-1977