1114688223 NPI number — SMITH & KOLB FAMILY PRACTICE, PLLC

Table of content: MRS. MADISON PAIGE PETERSEN BSW (NPI 1295073807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114688223 NPI number — SMITH & KOLB FAMILY PRACTICE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMITH & KOLB FAMILY PRACTICE, PLLC
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:
6
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:
1114688223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 OWEN DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-740-4361
Provider Business Mailing Address Fax Number:
910-488-4856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 OWEN DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-740-4361
Provider Business Practice Location Address Fax Number:
910-488-4856
Provider Enumeration Date:
01/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
BUFFY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE OFFICE MANAGER
Authorized Official Telephone Number:
910-740-4361

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1437827490 . This is a "NATIONAL PROVIDER IDENTIFIER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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