Provider Demographics
NPI:1699760702
Name:ENT CAROLINA PA
Entity type:Organization
Organization Name:ENT CAROLINA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BYRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-868-8400
Mailing Address - Street 1:2520 ABERDEEN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0635
Mailing Address - Country:US
Mailing Address - Phone:704-868-8400
Mailing Address - Fax:704-868-8493
Practice Address - Street 1:2520 ABERDEEN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0635
Practice Address - Country:US
Practice Address - Phone:704-868-8400
Practice Address - Fax:704-868-8493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0171MOtherBLUE CROSS BLUE SHIELD
NCCA9743OtherRAILROAD MEDICARE
NC890171MMedicaid
NC0930362OtherAETNA HEALTHPLAN
NC0171MOtherBLUE CROSS BLUE SHIELD