1679525604 NPI number — BERTRAND FOTE MD

Table of content: BERTRAND FOTE MD (NPI 1679525604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679525604 NPI number — BERTRAND FOTE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOTE
Provider First Name:
BERTRAND
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1679525604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 WHITE TAIL TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAXHAW
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28173-7215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-277-4461
Provider Business Mailing Address Fax Number:
704-243-6168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 MOCKSVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28144-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-805-1300
Provider Business Practice Location Address Fax Number:
904-805-1302
Provider Enumeration Date:
05/17/2006

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: 207P00000X , with the licence number:  200400332 , 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: 1360F . This is a "BLUE CROSS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00156562 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891360F , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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