1922104066 NPI number — OWEN DRIVE SURGICAL CLINIC, PA

Table of content: (NPI 1922104066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922104066 NPI number — OWEN DRIVE SURGICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OWEN DRIVE SURGICAL CLINIC, 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:
1922104066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ETOWAH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28729-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-484-0101
Provider Business Mailing Address Fax Number:
910-484-2563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1617 OWEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-484-0101
Provider Business Practice Location Address Fax Number:
910-484-2563
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAUDHURI
Authorized Official First Name:
DEBI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-484-0101

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89-0255A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0255A . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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