1235554502 NPI number — NORTHWEST NEUROLOGY, PLLC

Table of content: (NPI 1235554502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235554502 NPI number — NORTHWEST NEUROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST NEUROLOGY, 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:
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:
1235554502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 MEADOWVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILKESBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28697-7348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-838-7111
Provider Business Mailing Address Fax Number:
336-838-4299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 MEADOWVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKESBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28697-7348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-838-7111
Provider Business Practice Location Address Fax Number:
336-838-4299
Provider Enumeration Date:
02/24/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SEALES
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
NEUROLOGIST
Authorized Official Telephone Number:
336-838-7111

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  35748 , 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: 1952393605 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2173867 . This is a "NC MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".