1972719698 NPI number — CARRBORO FAMILY MEDICINE CENTER, 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 1972719698 NPI number — CARRBORO FAMILY MEDICINE CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARRBORO FAMILY MEDICINE CENTER, 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:
1972719698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 JONES FERRY RD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
CARRBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27510-6113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-929-1747
Provider Business Mailing Address Fax Number:
919-933-5168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 JONES FERRY RD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
CARRBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27510-6113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-929-1747
Provider Business Practice Location Address Fax Number:
919-933-5168
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BULLOCK
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
919-929-1747

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1972719698 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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