Healthcare Provider Details

I. General information

NPI: 1588025381
Provider Name (Legal Business Name): SALEM PEDIATRIC EAR AND AIRWAY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SAINT GEORGE SQUARE CT SUITE 364
WINSTON SALEM NC
27103-1356
US

IV. Provider business mailing address

615 SAINT GEORGE SQUARE CT SUITE 364
WINSTON SALEM NC
27103-1356
US

V. Phone/Fax

Practice location:
  • Phone: 336-245-4972
  • Fax: 336-450-1676
Mailing address:
  • Phone: 336-245-4972
  • Fax: 336-450-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number2006-00303
License Number StateNC

VIII. Authorized Official

Name: ADELE KAREN EVANS
Title or Position: MEMBER MANAGER
Credential: MD
Phone: 919-699-2269