1124080445 NPI number — DR. ELIZABETH A ALBERTSON M.D.

Table of content: DR. ELIZABETH A ALBERTSON M.D. (NPI 1124080445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124080445 NPI number — DR. ELIZABETH A ALBERTSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALBERTSON
Provider First Name:
ELIZABETH
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALBERTSON
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1124080445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4541 CHINABERRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27106-4290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-972-1910
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 GLEN COVE DR # 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04856-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-301-5400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2006

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: 208800000X , with the licence number:  35996 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: MD22553 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2236346C . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2344759 . This is a "MEDICARE, GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00193953 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891032Y , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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