1063429561 NPI number — JOHN F MAHONEY MD

Table of content: JOHN F MAHONEY MD (NPI 1063429561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063429561 NPI number — JOHN F MAHONEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHONEY
Provider First Name:
JOHN
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063429561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-446-4000
Provider Business Mailing Address Fax Number:
704-446-4098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15830 BALLANTYNE MEDICAL PLACE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-3297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-446-4000
Provider Business Practice Location Address Fax Number:
704-446-4098
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  34077 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: 34077 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N34077 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063429561 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53737 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8953737 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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