1063684215 NPI number — DR. CAROL V PETILLO PHD

Table of content: MS. RACHEL E SHEPARD MSW (NPI 1942426796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063684215 NPI number — DR. CAROL V PETILLO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETILLO
Provider First Name:
CAROL
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1063684215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1330 BOILING SPRINGS RD
Provider Second Line Business Mailing Address:
STE 1400
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29303-4205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-278-1273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6035 FAIRVIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-295-3300
Provider Business Practice Location Address Fax Number:
704-295-3468
Provider Enumeration Date:
03/27/2008

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: 231H00000X , with the licence number:  7312 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , with the licence number: 3886 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1618R . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5939044 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7413356 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 770333 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01044436 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 9873230 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P01450607 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 30111366 . This is a "SELECT HEALTH OF SOUTH CAROLINA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SA1085 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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