1184945925 NPI number — DR. NILES EDEMEKA CARTER MD

Table of content: DR. NILES EDEMEKA CARTER MD (NPI 1184945925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184945925 NPI number — DR. NILES EDEMEKA CARTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTER
Provider First Name:
NILES
Provider Middle Name:
EDEMEKA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ITA
Provider Other First Name:
NILES
Provider Other Middle Name:
EDEMEKA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184945925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
395 WESTFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOBLESVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46060-1425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-773-0760
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 S. RIBAUT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ROYAL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-322-1800
Provider Business Practice Location Address Fax Number:
843-986-0229
Provider Enumeration Date:
06/16/2010

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: 207V00000X , with the licence number:  37500 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 01079362A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 375007 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300007706 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".