1891960241 NPI number — PINE HAVEN FAMILY MEDICINE 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 1891960241 NPI number — PINE HAVEN FAMILY MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE HAVEN FAMILY MEDICINE 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:
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:
1891960241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 WEST ACADEMY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDLEMAN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-498-1200
Provider Business Mailing Address Fax Number:
336-498-1206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 WEST ACADEMY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDLEMAN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-498-1200
Provider Business Practice Location Address Fax Number:
336-498-1206
Provider Enumeration Date:
04/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SLATOSKY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
336-498-1200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  9900682 , 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: 891212U , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2348546 . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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