1083927313 NPI number — CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC

Table of content: (NPI 1083927313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083927313 NPI number — CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC
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:
6
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:
1083927313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28309-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-615-6448
Provider Business Mailing Address Fax Number:
910-615-5070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 FAYETTEVILLE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAEFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-615-3100
Provider Business Practice Location Address Fax Number:
910-486-2154
Provider Enumeration Date:
07/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NAGOWSKI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-615-6700

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  H0213 , 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: PENDING , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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