1639146780 NPI number — DR. WALTER LEE FANNING JR. M.D.

Table of content: DR. WALTER LEE FANNING JR. M.D. (NPI 1639146780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639146780 NPI number — DR. WALTER LEE FANNING JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FANNING
Provider First Name:
WALTER
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1639146780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MEDICAL ARTS DRIVE
Provider Second Line Business Mailing Address:
SUITE 280 CAROLINAS MEDICAL CENTER NORTH EAST
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-0935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-403-1766
Provider Business Mailing Address Fax Number:
704-403-1096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 MEDICAL PARK DR STE 280
Provider Second Line Business Practice Location Address:
CAROLINAS MEDICAL CENTER NORTH EAST
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28025-0935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-403-1766
Provider Business Practice Location Address Fax Number:
704-403-1096
Provider Enumeration Date:
03/07/2006

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: 207RI0200X , with the licence number:  2006-00672 , 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: 1527547 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 00339806 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 142K2 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2055819A . This is a "MEDICARE PTAN, INDIVIDUAL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 190800 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 808032 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4302912 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 232009 . This is a "MEDICARE PTAN, GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5903747 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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