1063476083 NPI number — NICHOLAS AUDEH MD

Table of content: NICHOLAS AUDEH MD (NPI 1063476083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063476083 NPI number — NICHOLAS AUDEH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUDEH
Provider First Name:
NICHOLAS
Provider Middle Name:
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:
1063476083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 PROVIDENCE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28207-1468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-749-5800
Provider Business Mailing Address Fax Number:
704-973-0815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 MCGUIRE PL
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23601-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-596-2762
Provider Business Practice Location Address Fax Number:
757-595-2001
Provider Enumeration Date:
04/14/2006

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: 207L00000X , with the licence number:  0101052183 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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