1528055621 NPI number — TENET UNIFOUR URGENT CARE CENTER LLC

Table of content: (NPI 1528055621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528055621 NPI number — TENET UNIFOUR URGENT CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENET UNIFOUR URGENT CARE CENTER LLC
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:
FRYECARE URGENT CARE - CONOVER
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:
1528055621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 741330
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:
30384-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-267-0551
Provider Business Mailing Address Fax Number:
828-267-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 FAIRGROVE CHURCH RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONOVER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28613-9090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-267-0551
Provider Business Practice Location Address Fax Number:
828-267-0351
Provider Enumeration Date:
10/04/2005

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: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01766 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CG6339 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89011F3 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".