1881624955 NPI number — CAROLINA PODIATRY ASSOCIATES, LLC

Table of content: (NPI 1881624955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881624955 NPI number — CAROLINA PODIATRY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA PODIATRY ASSOCIATES, 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:
CAROLINA PODIATRY & MEDICAL SPECIALTIES
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:
1881624955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 777
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAEFORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28376-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-904-0648
Provider Business Mailing Address Fax Number:
910-904-1810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAEFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28376-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-904-0648
Provider Business Practice Location Address Fax Number:
910-904-1810
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NETTLES
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
910-904-0648

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  24580 , 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: 016TM . This is a "BLUECROSSBLUESHIELD NUMBE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89016TM , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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