1619084647 NPI number — BEVERLY MCCORKLE CONDER NP

Table of content: (NPI 1316382930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619084647 NPI number — BEVERLY MCCORKLE CONDER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONDER
Provider First Name:
BEVERLY
Provider Middle Name:
MCCORKLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1619084647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
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:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-887-4530
Provider Business Mailing Address Fax Number:
704-887-4531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10030 GILEAD RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28078-7545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-887-4530
Provider Business Practice Location Address Fax Number:
704-887-4531
Provider Enumeration Date:
08/24/2006

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: 363LA2200X , with the licence number:  0050-00682 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 1-130234 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 5000682 , 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: 7003749 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00297346 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05673386 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q53832 . This is a "VIVA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: NP0911 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130679 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051118877 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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