1396874285 NPI number — BRUNSWICK FOOT & ANKLE SURGERY

Table of content: (NPI 1396874285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396874285 NPI number — BRUNSWICK FOOT & ANKLE SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUNSWICK FOOT & ANKLE SURGERY
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:
1396874285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 DOCTORS CIR
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
SUPPLY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28462-4097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-751-9120
Provider Business Mailing Address Fax Number:
919-751-9170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 DOCTORS CIR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462-4097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-751-9120
Provider Business Practice Location Address Fax Number:
919-751-9170
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIBLER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-751-9120

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  452 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 890806X , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5199990001 . This is a "MEDICARE DMERC PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com