MEDICARE: EAR NOSE THROAT & AUDIOLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366632655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAR NOSE THROAT & AUDIOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	8334 PINEVILLE MATTHEWS RD
Second Line	:	SUITE 103-151
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3774
Country	:	US
Telephone Number	:	803-328-3686
Fax Number	:	803-328-9889

Provider Business Practice Location Address
First Line	:	744 ARDEN LN
Second Line	:	SUITE 200
City	:	ROCK HILL
State	:	SC
Zip	:	29732-2984
Country	:	US
Telephone Number	:	803-328-3686
Fax Number	:	803-328-9889

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. LEROY BROADNAX
Credential	:
Telephone Number	:	803-328-3686

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	08/14/2015

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