1588613129 NPI number — ENGLISH B BLACK I PAC

Table of content: ENGLISH B BLACK I PAC (NPI 1588613129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588613129 NPI number — ENGLISH B BLACK I PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
ENGLISH
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
I
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAKER GLAUSER
Provider Other First Name:
ENGLISH
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588613129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4010 MENDENHALL OAKS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27265-8076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-887-3195
Provider Business Mailing Address Fax Number:
336-887-3194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4010 MENDENHALL OAKS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27265-8076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-887-3195
Provider Business Practice Location Address Fax Number:
336-887-3194
Provider Enumeration Date:
05/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA19680 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0001-04013 , 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: 2760634 . This is a "MEDICARE ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".