1932297264 NPI number — EASTOVER FOOT & ANKLE 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 1932297264 NPI number — EASTOVER FOOT & ANKLE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTOVER FOOT & ANKLE 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:
1932297264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1539
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28106-1539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-841-4000
Provider Business Mailing Address Fax Number:
704-841-4338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
428 N. TRADE STREET
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-5017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-841-4000
Provider Business Practice Location Address Fax Number:
704-841-4338
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FUTERMAN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-841-4000

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  200001392347 , 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: 0172M . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890172M , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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