1821112673 NPI number — BRUNSWICK CARDIOLOGY, PC

Table of content: (NPI 1821112673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821112673 NPI number — BRUNSWICK CARDIOLOGY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUNSWICK CARDIOLOGY, PC
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:
BRUNSWICK CARDIOLOGY,PC
Provider Other Organization Name Type Code:
3
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:
1821112673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUPPLY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28462-0427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-755-7192
Provider Business Mailing Address Fax Number:
910-755-7194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 MEDICAL CAMPUS DR
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462-4096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-755-7192
Provider Business Practice Location Address Fax Number:
910-755-7194
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SEDER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-755-7192

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  35196 , 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: 561776208B . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8975177 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2207970 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 75177 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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