1497490957 NPI number — OPEN WATER MEDICAL, PA

Table of content: (NPI 1497490957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497490957 NPI number — OPEN WATER MEDICAL, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN WATER MEDICAL, 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:
1497490957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620C LIVE OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28516-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-728-5737
Provider Business Mailing Address Fax Number:
252-728-5739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 OFFICE PARK 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:
28546-7326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-353-9906
Provider Business Practice Location Address Fax Number:
910-353-4853
Provider Enumeration Date:
04/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TISHA
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
252-728-5737

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1750482493 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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