1083696926 NPI number — TENET CENTRAL CAROLINA PHYSICIANS INC

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 1083696926 NPI number — TENET CENTRAL CAROLINA PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENET CENTRAL CAROLINA PHYSICIANS INC
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:
MID CAROLINA CROSSROADS SURGICAL CLINIC
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:
1083696926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-774-1277
Provider Business Mailing Address Fax Number:
919-774-1101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 WICKER ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-1277
Provider Business Practice Location Address Fax Number:
919-774-1101
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BURTNETT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
KYLE
Authorized Official Title or Position:
SVP OF OUTPATIENT SERVICES, TENET
Authorized Official Telephone Number:
469-893-2153

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5903334 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF0988 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017MY . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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