1275708125 NPI number — NICHOLAS J FITZSIMONS MD

Table of content: NICHOLAS J FITZSIMONS MD (NPI 1275708125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275708125 NPI number — NICHOLAS J FITZSIMONS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZSIMONS
Provider First Name:
NICHOLAS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1275708125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36488
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:
28236-6488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-248-3400
Provider Business Mailing Address Fax Number:
704-337-8387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10650 PARK RD
Provider Second Line Business Practice Location Address:
SUITE # 320
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-541-8207
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2008

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:  117286 , 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: N01705 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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