1083696926 NPI number — TENET CENTRAL CAROLINA PHYSICIANS INC

Table of content: (NPI 1083696926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083696926 NPI number — TENET CENTRAL CAROLINA PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENET CENTRAL CAROLINA PHYSICIANS INC
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:
MID CAROLINA CROSSROADS SURGICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1083696926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-774-1277
Provider Business Mailing Address Fax Number:
919-774-1101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 WICKER ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-1277
Provider Business Practice Location Address Fax Number:
919-774-1101
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BURTNETT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
KYLE
Authorized Official Title or Position:
SVP OF OUTPATIENT SERVICES, TENET
Authorized Official Telephone Number:
469-893-2153

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5903334 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF0988 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017MY . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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