1063556728 NPI number — DOUGLAS DUSSEL PRITCHARD MD PLLC

Table of content: (NPI 1063556728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063556728 NPI number — DOUGLAS DUSSEL PRITCHARD MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS DUSSEL PRITCHARD MD PLLC
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:
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:
1063556728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 SIGNAL HILL DRIVE EXT
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
STATESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28625-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-818-0480
Provider Business Mailing Address Fax Number:
704-818-0490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 SIGNAL HILL DRIVE EXT
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28625-4337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-818-0480
Provider Business Practice Location Address Fax Number:
704-818-0490
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRITCHARD
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
DUSSEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-818-0840

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  18045 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X , with the licence number: 10845 , 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: 132YC . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7870927 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 196255 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 209727A . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DG1403 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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