=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538189279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAYETTEVILLE OTOLARYNGOLOGY HEAD AND NECK SURGERY P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1839 QUIET CV
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-1463
-----------------------------------------------------
Fax | 910-323-1575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1839 QUIET CV
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-1463
-----------------------------------------------------
Fax | 910-323-1575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. GWENDOLYN C PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-323-1463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------