1093018095 NPI number — CAROLINA MEDICAL & MANAGEMENT CONSULTANTS, PLLC

Table of content: (NPI 1093018095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093018095 NPI number — CAROLINA MEDICAL & MANAGEMENT CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA MEDICAL & MANAGEMENT CONSULTANTS, PLLC
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:
1093018095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 697
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDENTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27932-0697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-339-4525
Provider Business Mailing Address Fax Number:
888-379-3488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 BAY POINT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDENTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27932-8032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-339-4525
Provider Business Practice Location Address Fax Number:
888-379-3488
Provider Enumeration Date:
12/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SEVERA
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
252-339-4525

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  NC200400743 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89137KR , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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