1649373788 NPI number — FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA

Table of content: (NPI 1649373788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649373788 NPI number — FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC 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:
1649373788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1689
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ETOWAH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28729-1689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-891-5524
Provider Business Mailing Address Fax Number:
828-891-4069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3616 CAPE CENTER DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-868-6730
Provider Business Practice Location Address Fax Number:
910-829-9649
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAHMAN
Authorized Official First Name:
MOHAMMED
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
910-868-6730

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 891163K , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1163K . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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