1164431755 NPI number — ELISA M CARTER PA

Table of content: ELISA M CARTER PA (NPI 1164431755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164431755 NPI number — ELISA M CARTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTER
Provider First Name:
ELISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1164431755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11314
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-842-4481
Provider Business Mailing Address Fax Number:
757-312-3135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PLANK BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-331-1829
Provider Business Practice Location Address Fax Number:
252-331-2916
Provider Enumeration Date:
08/05/2006

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: 207RC0000X , with the licence number:  0110001676 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0110001676 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010385407 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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