1740387406 NPI number — BRIAN PATRICK WALL MD

Table of content: BRIAN PATRICK WALL MD (NPI 1740387406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740387406 NPI number — BRIAN PATRICK WALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
BRIAN
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1740387406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28370-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-295-6007
Provider Business Mailing Address Fax Number:
910-215-0179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 MILLSTONE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HILLSBOROUGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27278-8776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-245-5400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2006

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: 2084P0800X , with the licence number:  9801544 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 9801544 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5902265 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com