1285616854 NPI number — DR. MARC DEMASON M.D.

Table of content: DR. MARC DEMASON M.D. (NPI 1285616854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285616854 NPI number — DR. MARC DEMASON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMASON
Provider First Name:
MARC
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1285616854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 THOMPSON ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
EDEN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27288-5068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-623-9118
Provider Business Mailing Address Fax Number:
336-623-1902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 THOMPSON ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EDEN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27288-5068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-623-9118
Provider Business Practice Location Address Fax Number:
336-623-1902
Provider Enumeration Date:
11/18/2005

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: 208600000X , with the licence number:  27157 , 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: 032953 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 28320 . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 37469 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4155 . This is a "PARTNERS MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5778367 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7350325 . This is a "VIRGINIA MEDICAL ASSISTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7928320 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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