1679558753 NPI number — DR. WILLIAM CHARLES VANNESS III MD

Table of content: DR. WILLIAM CHARLES VANNESS III MD (NPI 1679558753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679558753 NPI number — DR. WILLIAM CHARLES VANNESS III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANNESS
Provider First Name:
WILLIAM
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
1679558753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 MORLAKE DR
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-9232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-663-3777
Provider Business Mailing Address Fax Number:
704-664-6615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 MORLAKE DR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-663-3777
Provider Business Practice Location Address Fax Number:
704-664-6615
Provider Enumeration Date:
12/12/2005

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: 208100000X , with the licence number:  200001012 , 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: 89126TU , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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