1710073606 NPI number — EAGLE PHYSICIANS AND ASSOCIATES PA

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 1710073606 NPI number — EAGLE PHYSICIANS AND ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE PHYSICIANS AND ASSOCIATES 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:
6
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:
1710073606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14883
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27415-4883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-282-0376
Provider Business Mailing Address Fax Number:
336-282-0379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 ROBERT PORCHER WAY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27410-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-282-0376
Provider Business Practice Location Address Fax Number:
336-282-0379
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
DIRECTOR, EAGLE BUSINESS SERVICES
Authorized Official Telephone Number:
336-268-3201

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: 0287U . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890287U , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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