Provider Demographics
NPI:1699782334
Name:CAROLINAS EAR NOSE & THROAT CENTER
Entity type:Organization
Organization Name:CAROLINAS EAR NOSE & THROAT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LIZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-754-2920
Mailing Address - Street 1:14 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-3350
Mailing Address - Country:US
Mailing Address - Phone:910-754-2920
Mailing Address - Fax:910-754-2268
Practice Address - Street 1:14 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-3350
Practice Address - Country:US
Practice Address - Phone:910-754-2920
Practice Address - Fax:910-754-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35160207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0295NOtherBCBS NC
NC8952324Medicaid
NC0295NOtherBCBS NC
2327682Medicare ID - Type Unspecified