1710942610 NPI number — FARMVILLE INTERNAL MEDICINE PA

Table of content: (NPI 1710942610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710942610 NPI number — FARMVILLE INTERNAL MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARMVILLE INTERNAL MEDICINE 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:
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:
1710942610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3485 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27828-1466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-753-3193
Provider Business Mailing Address Fax Number:
252-753-7966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3485 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27828-1466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-753-3193
Provider Business Practice Location Address Fax Number:
252-753-7966
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARANA
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
ENRIQUE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-753-3193

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20000090 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: 200000090 , 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: 89126A3 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF6187 . This is a "RAILROAD MEDICARE (GROUP NUMBER)" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00379704 . This is a "RAILROAD MEDICARE (PIN)" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 126A3 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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