=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649216631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIEDMONT EAR, NOSE & THROAT ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 CHARLOIS BLVD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-3368
-----------------------------------------------------
Fax | 336-659-2446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 CHARLOIS BLVD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-3361
-----------------------------------------------------
Fax | 336-659-2446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | THOMAS SCOTT MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-714-1039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 40141
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------