Provider Demographics
NPI:1699739193
Name:NORTHEAST EAR NOSE AND THROAT CENTER PA
Entity type:Organization
Organization Name:NORTHEAST EAR NOSE AND THROAT CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:DZIADZIOLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-788-1103
Mailing Address - Street 1:3003 DALE EARNHARDT BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-1406
Mailing Address - Country:US
Mailing Address - Phone:704-788-1103
Mailing Address - Fax:704-786-1414
Practice Address - Street 1:3003 DALE EARNHARDT BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-1406
Practice Address - Country:US
Practice Address - Phone:704-788-1103
Practice Address - Fax:704-786-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700538174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901322Medicaid
NC01322OtherBCBSNC
NC01322OtherBCBSNC