Provider Demographics
NPI:1306870902
Name:LAKE NORMAN EARS NOSE AND THROAT PA
Entity type:Organization
Organization Name:LAKE NORMAN EARS NOSE AND THROAT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WETTREICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-664-9368
Mailing Address - Street 1:140 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-664-9638
Mailing Address - Fax:704-664-1859
Practice Address - Street 1:140 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-664-9638
Practice Address - Fax:704-664-1859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1781857OtherUNITED HEALTHCARE
NC8986676Medicaid
NC0270KOtherBCBS
NC5912716Medicaid
NC0270KOtherBCBS