1316090608 NPI number — JACKSONVILLE ORTHOPEDIC CLINIC, P.A.

Table of content: CHELSEA PANCARI RD (NPI 1902355191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316090608 NPI number — JACKSONVILLE ORTHOPEDIC CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE ORTHOPEDIC CLINIC, P.A.
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:
1316090608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28546-6328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28546-6328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-353-4500
Provider Business Practice Location Address Fax Number:
910-353-5610
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
NOEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-353-4500

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8901899 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01899 . This is a "BLUE CROS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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