1740472992 NPI number — DAWSON STREET URGENT CARE &MEDICAL CENTER,PA

Table of content: (NPI 1740472992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740472992 NPI number — DAWSON STREET URGENT CARE &MEDICAL CENTER,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAWSON STREET URGENT CARE &MEDICAL CENTER,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:
1740472992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 S 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28401-4506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-343-3349
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 DAWSON ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401-5712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-667-0470
Provider Business Practice Location Address Fax Number:
910-667-0475
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEMAS
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-343-3349

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2335627 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5907985 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28322 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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