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General NPI Number Information
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NPI Number | 1588025381
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Entity Type | Organization
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Legal Business Name | SALEM PEDIATRIC EAR AND AIRWAY CENTER, PLLC
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Dates
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Enumeration Date | 03/08/2016
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Last Update Date | 03/08/2016
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Provider Practice Location Address
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Address Line | 615 SAINT GEORGE SQUARE CT SUITE 364
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City | WINSTON SALEM
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State | NC
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Zip | 27103-1356
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Country | US
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Telephone | 336-245-4972
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Fax | 336-450-1676
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Provider Business Mailing Address
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Address Line | 615 SAINT GEORGE SQUARE CT SUITE 364
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City | WINSTON SALEM
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State | NC
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Zip | 27103-1356
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Country | US
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Telephone | 336-245-4972
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Fax | 336-450-1676
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Authorized Official
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Title or Position | MEMBER MANAGER
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Name | ADELE KAREN EVANS
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Credential | MD
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Telephone | 919-699-2269
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YP0228X
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Taxonomy Name | Pediatric Otolaryngology Physician
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License Number | 2006-00303
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License Number State | NC
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