1073665337 NPI number — SWANNANOA VALLEY FAMILY MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073665337 NPI number — SWANNANOA VALLEY FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWANNANOA VALLEY FAMILY MEDICINE
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:
1073665337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2296 US 70 HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANNANOA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28778-8209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-686-5232
Provider Business Mailing Address Fax Number:
828-686-7269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2296 US 70 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWANNANOA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28778-8209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-686-5232
Provider Business Practice Location Address Fax Number:
828-686-7269
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
JANEY
Authorized Official Middle Name:
WOOD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-686-5232

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  24779 , 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: 210331 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0170087 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 152692 . This is a "MID SOUTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8948212 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48212 01649 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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