1386843779 NPI number — COMPREHENSIVE MEDICAL ASSOCIATES, PLLC

Table of content: (NPI 1386843779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386843779 NPI number — COMPREHENSIVE MEDICAL ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE MEDICAL ASSOCIATES, 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:
SHERRY ZILBERT IKALOWYCH, MD
Provider Other Organization Name Type Code:
4
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:
1386843779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5130 SOUTHPORT SUPPLY RD SE
Provider Second Line Business Mailing Address:
SUITE 101 A
Provider Business Mailing Address City Name:
SOUTHPORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28461-9261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-454-4032
Provider Business Mailing Address Fax Number:
910-454-4033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 SOUTHPORT SUPPLY RD SE
Provider Second Line Business Practice Location Address:
SUITE 101 A
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461-9261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-454-4032
Provider Business Practice Location Address Fax Number:
910-454-4033
Provider Enumeration Date:
07/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IKALOWYCH
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
Z
Authorized Official Title or Position:
PHYSICIAN/OWENER
Authorized Official Telephone Number:
910-454-4032

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  200500060 , 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: 5902156 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9406199 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 140K2 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8089924 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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