1497716211 NPI number — DR. WALTER S FASOLAK DO

Table of content: DR. WALTER S FASOLAK DO (NPI 1497716211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497716211 NPI number — DR. WALTER S FASOLAK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FASOLAK
Provider First Name:
WALTER
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1497716211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749
Provider Second Line Business Mailing Address:
SOUTHERN PINES WOMENS HEALTH CENTER PC
Provider Business Mailing Address City Name:
SOUTHERN PINES
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28388-0749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-692-7928
Provider Business Mailing Address Fax Number:
910-692-5962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 APPLECROSS RD
Provider Second Line Business Practice Location Address:
SOUTHERN PINES WOMENS HEALTH CENTER PC
Provider Business Practice Location Address City Name:
SOUTHERN PINES
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-692-7928
Provider Business Practice Location Address Fax Number:
910-692-5962
Provider Enumeration Date:
03/31/2006

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: 207V00000X , with the licence number:  39728 , 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: 8931369 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q39728 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31369 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9663436 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 980000066 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: FH1000115 . This is a "FIRST CAROLINA CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42653 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".




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