1740348838 NPI number — BURLINGTON MEDICAL PRACTICE, PA

Table of content: (NPI 1740348838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740348838 NPI number — BURLINGTON MEDICAL PRACTICE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURLINGTON MEDICAL PRACTICE, 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:
1740348838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1183 UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE 105-410
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27215-8303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-584-5200
Provider Business Mailing Address Fax Number:
336-584-0099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1248 HUFFMAN MILL RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27215-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-584-5200
Provider Business Practice Location Address Fax Number:
336-584-0099
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLOCKER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-584-5200

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  9600215 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 200600619 , 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: 199001 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7761536 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: XXXXXX944 . This is a "UHC---MEDICARE COMPLETE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 346879 . This is a "GREAT WEST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 018KU . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6579469 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891037P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: C8899 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com