1720028558 NPI number — PIEDMONT SPINE SPECIALISTS, PA

Table of content: (NPI 1720028558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720028558 NPI number — PIEDMONT SPINE SPECIALISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIEDMONT SPINE SPECIALISTS, 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:
1720028558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16934
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27516-6934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-442-2407
Provider Business Mailing Address Fax Number:
919-967-6647

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3480 WAKE FOREST RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-7376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-781-4541
Provider Business Practice Location Address Fax Number:
919-781-4812
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENTLEY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-781-4541

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , 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: 5902775 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017P7 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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