1114100872 NPI number — MEDAC HEALTH SERVICES, PA

Table of content: (NPI 1114100872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114100872 NPI number — MEDAC HEALTH SERVICES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDAC HEALTH SERVICES, 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:
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:
1114100872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 CENTERVIEW DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-3226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-791-0075
Provider Business Mailing Address Fax Number:
615-656-2745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8115 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28411-8427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-686-1972
Provider Business Practice Location Address Fax Number:
910-686-2129
Provider Enumeration Date:
12/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALONEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEA
Authorized Official Telephone Number:
616-656-2750

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 07651 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC2877 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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