1508850587 NPI number — WEST COLUMBUS FAMILY PRACTICE PA

Table of content: (NPI 1508850587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508850587 NPI number — WEST COLUMBUS FAMILY PRACTICE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST COLUMBUS FAMILY PRACTICE PA
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:
1508850587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHADBOURN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28431-0325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-654-1701
Provider Business Mailing Address Fax Number:
910-654-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 N BROWN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHADBOURN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28431-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-654-1701
Provider Business Practice Location Address Fax Number:
910-654-5701
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BEAVER
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO OWNER
Authorized Official Telephone Number:
910-654-1701

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36494 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 344630A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0247Y . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 344634A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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