1376326850 NPI number — MICUM HEALTH PLLC

Table of content: (NPI 1376326850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376326850 NPI number — MICUM HEALTH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICUM HEALTH 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:
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:
1376326850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4311 SCHOOL HOUSE CMNS # 174
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28075-7510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-470-8303
Provider Business Mailing Address Fax Number:
704-997-1588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10130 MALLARD CREEK RD STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-6003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-470-8303
Provider Business Practice Location Address Fax Number:
704-997-1588
Provider Enumeration Date:
08/17/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOULLARD
Authorized Official First Name:
TOVAKYSHE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
800-470-8303

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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