1871551911 NPI number — METROLINA SURGICAL SPECIALISTS, PLLC

Table of content: (NPI 1871551911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871551911 NPI number — METROLINA SURGICAL SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METROLINA SURGICAL SPECIALISTS, PLLC
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:
1871551911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1928 RANDOLPH RD
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28207-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-375-0404
Provider Business Mailing Address Fax Number:
704-375-0705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1928 RANDOLPH RD
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28207-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-375-0404
Provider Business Practice Location Address Fax Number:
704-375-0705
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERUCHALU
Authorized Official First Name:
OBINNA
Authorized Official Middle Name:
NNAEMKA
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
704-375-0404

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8930776 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10039 . This is a "PARTNERS MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1036L . 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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