1043207616 NPI number — MR. ROGER LEE MCCAULEY MD

Table of content: MR. ROGER LEE MCCAULEY MD (NPI 1043207616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043207616 NPI number — MR. ROGER LEE MCCAULEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAULEY
Provider First Name:
ROGER
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1043207616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 KIMEL PARK DR
Provider Second Line Business Mailing Address:
STE 115
Provider Business Mailing Address City Name:
WINSTON-SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-768-6930
Provider Business Mailing Address Fax Number:
336-768-6328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 KIMEL PARK DR
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-6951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-768-6930
Provider Business Practice Location Address Fax Number:
336-768-6328
Provider Enumeration Date:
09/29/2005

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: 2084P0800X , with the licence number:  20823 , 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: 8955760 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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