1568620839 NPI number — PHILLIP MCIVER DDS PA

Table of content: (NPI 1568620839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568620839 NPI number — PHILLIP MCIVER DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIP MCIVER DDS PA
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:
EASTERN PINES ORAL & MAXILLOFACIAL SURGERY
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:
1568620839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 OLDE WATERFORD WAY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451-4125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-383-3004
Provider Business Mailing Address Fax Number:
910-383-0121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 OLDE WATERFORD WAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28451-4125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-383-3004
Provider Business Practice Location Address Fax Number:
910-383-0121
Provider Enumeration Date:
05/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CONSULTANT
Authorized Official Telephone Number:
910-793-9545

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  8366 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 051257 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 8366 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5909205 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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