Healthcare Provider Details

I. General information

NPI: 1649216631
Provider Name (Legal Business Name): PIEDMONT EAR, NOSE & THROAT ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3368
  • Fax: 336-659-2446
Mailing address:
  • Phone: 336-768-3361
  • Fax: 336-659-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number40141
License Number StateNC

VIII. Authorized Official

Name: THOMAS SCOTT MARTIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 336-714-1039