Healthcare Provider Details

I. General information

NPI: 1447445036
Provider Name (Legal Business Name): CHARLOTTE EYE EAR NOSE & THROAT ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 E ROOSEVELT BLVD
MONROE NC
28112-4017
US

IV. Provider business mailing address

6035 FAIRVIEW RD
CHARLOTTE NC
28210-3256
US

V. Phone/Fax

Practice location:
  • Phone: 704-295-3725
  • Fax: 704-838-8494
Mailing address:
  • Phone: 704-295-3000
  • Fax: 704-838-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAG S GILL
Title or Position: CEO
Credential: SCD
Phone: 704-295-3000