Provider Demographics
NPI:1336185842
Name:EASTERN ENT SINUS AND ALLERGY CENTER, PA
Entity type:Organization
Organization Name:EASTERN ENT SINUS AND ALLERGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-735-9146
Mailing Address - Street 1:2707 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9458
Mailing Address - Country:US
Mailing Address - Phone:919-735-9146
Mailing Address - Fax:919-735-0582
Practice Address - Street 1:2707 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9458
Practice Address - Country:US
Practice Address - Phone:919-735-9146
Practice Address - Fax:919-735-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901642Medicaid
NC01642OtherBCBSNC
NC8901642Medicaid
NC0460110001Medicare NSC