1376682344 NPI number — MARK H NELSON MD PA

Table of content: (NPI 1376682344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376682344 NPI number — MARK H NELSON MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK H NELSON MD PA
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:
1376682344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 HIGHLAND OAKS DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-7105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-659-1528
Provider Business Mailing Address Fax Number:
336-659-1980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 HIGHLAND OAKS DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-7105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-659-1528
Provider Business Practice Location Address Fax Number:
336-659-1980
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-659-1528

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  33109 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0800585 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2700323 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8962094 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 698 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4557306003 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10236300 . This is a "VOCATIONAL REHAB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 248246 . This is a "BCBS VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4557306002 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1417953654 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 10053 . This is a "OPTICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DN9117 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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