1770778342 NPI number — TARHEEL SURGICAL SPECIALISTS, LLC

Table of content: (NPI 1770778342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770778342 NPI number — TARHEEL SURGICAL SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TARHEEL SURGICAL SPECIALISTS, LLC
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:
1770778342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 S. MCCASKEY RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27892-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-799-3006
Provider Business Mailing Address Fax Number:
252-799-0955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S. MCCASKEY RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27892-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-799-3006
Provider Business Practice Location Address Fax Number:
252-799-0955
Provider Enumeration Date:
09/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TANNER
Authorized Official First Name:
TODD
Authorized Official Middle Name:
FITZGERALD
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
252-799-3006

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  9800713 , 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: 891153P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".