1730276890 NPI number — FAMILY TREE OB GYN, PA

Table of content: (NPI 1730276890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730276890 NPI number — FAMILY TREE OB GYN, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY TREE OB GYN, 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:
1730276890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 MAPLE AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
REIDSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27320-4652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-342-6063
Provider Business Mailing Address Fax Number:
336-342-7847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 MAPLE AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
REIDSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27320-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-342-6063
Provider Business Practice Location Address Fax Number:
336-342-7847
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
VAUGHN
Authorized Official Title or Position:
MD OWNER
Authorized Official Telephone Number:
336-342-6063

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  26070 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LG0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 89012KH , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012KH . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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