=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710932629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILMINGTON EAR NOSE & THROAT ASSOC., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 06/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2311 DELANEY RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-762-8754
-----------------------------------------------------
Fax | 910-762-0778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 DELANEY RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-762-8754
-----------------------------------------------------
Fax | 910-762-0778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | BRANDON TODD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-762-8754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------