1982693826 NPI number — DR. CHARLITA MANGRUM MD

Table of content: DR. CHARLITA MANGRUM MD (NPI 1982693826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982693826 NPI number — DR. CHARLITA MANGRUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGRUM
Provider First Name:
CHARLITA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1982693826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-384-7840
Provider Business Mailing Address Fax Number:
704-384-7830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 W HAMLET AVE
Provider Second Line Business Practice Location Address:
SUITE#5
Provider Business Practice Location Address City Name:
HAMLET
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28345-4523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-582-5166
Provider Business Practice Location Address Fax Number:
910-582-5168
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  200401535 , 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: 89016EO . This is a "CAROLINA ACCESS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89138KX , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138KX . This is a "BCBS INDIV" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00687321 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00267476 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: N01535 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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