1164873790 NPI number — ANNS FAMILY CARE #6

Table of content: RANDALL RAY SAMBERSON M.D. (NPI 1588677801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164873790 NPI number — ANNS FAMILY CARE #6

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANNS FAMILY CARE #6
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:
1164873790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5312 SIX FORKS RD STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27609-4458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-713-0930
Provider Business Mailing Address Fax Number:
919-790-6990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 TUCKLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-5257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-713-0930
Provider Business Practice Location Address Fax Number:
919-790-6990
Provider Enumeration Date:
06/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MAYO
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
919-713-0930

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  FCL-092-225 , 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: 3120 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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