1063457562 NPI number — GERIATRIC HEALTHCARE SERVICES, P.C.

Table of content: (NPI 1063457562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063457562 NPI number — GERIATRIC HEALTHCARE SERVICES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRIC HEALTHCARE SERVICES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARIA EUGENIA IRUELA, M.D.
Provider Other Organization Name Type Code:
5
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:
1063457562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27114-4416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-245-2764
Provider Business Mailing Address Fax Number:
336-923-2189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4016 HUNTSCROFT LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27106-4777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-245-2764
Provider Business Practice Location Address Fax Number:
336-245-2765
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IRUELA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
336-245-2764

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8901KA , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012KA . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CH6935 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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