1245563352 NPI number — EAGLE MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245563352 NPI number — EAGLE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE MEDICAL CENTER
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:
1245563352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 667889
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28266-7889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-926-5434
Provider Business Mailing Address Fax Number:
704-454-7388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1951 OLD STEELE CREEK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28208-5631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-926-5434
Provider Business Practice Location Address Fax Number:
704-454-7388
Provider Enumeration Date:
09/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ALUKO
Authorized Official First Name:
GBENGA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
704-975-6004

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2005-01333 , 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: 14096 . This is a "BLUECROSS BLUSHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5902507 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 278746 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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