1699722272 NPI number — PRODIGY HEALTHCARE SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699722272 NPI number — PRODIGY HEALTHCARE SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRODIGY HEALTHCARE SERVICES INC.
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:
1699722272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 HARGROVE ROAD
Provider Second Line Business Mailing Address:
SUITE 12
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27616-1949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-264-9769
Provider Business Mailing Address Fax Number:
919-341-5838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 HARGROVE ROAD
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27616-1949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-264-9769
Provider Business Practice Location Address Fax Number:
919-341-5838
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UWAKWE
Authorized Official First Name:
KELECHI
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
919-264-9769

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7704536 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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