1922077403 NPI number — MARLBORO GASTROENTEROLOGY ASSOCIATES PA

Table of content: (NPI 1922077403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922077403 NPI number — MARLBORO GASTROENTEROLOGY ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARLBORO GASTROENTEROLOGY ASSOCIATES 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:
6
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:
1922077403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 617
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENNETTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29512-0617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-479-6268
Provider Business Mailing Address Fax Number:
843-479-8076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 ENDO LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMLET
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28345-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-205-3035
Provider Business Practice Location Address Fax Number:
910-205-3062
Provider Enumeration Date:
03/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIDDLE
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MGR ADMINISTRATOR
Authorized Official Telephone Number:
843-479-9794

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  10779 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 27767 , 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: 0191F . This is a "BCBS GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: PC1896 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE8861 . This is a "SC RR MEDICARE GROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 890191F , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF8544 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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