1982797072 NPI number — FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC

Table of content: (NPI 1982797072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982797072 NPI number — FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC
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:
1982797072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 CAPE CT
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-4404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-678-8611
Provider Business Mailing Address Fax Number:
910-678-8100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 CAPE CT
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-678-8611
Provider Business Practice Location Address Fax Number:
910-678-8100
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEV
Authorized Official First Name:
GAUTAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DOCTOR PRESIDENT
Authorized Official Telephone Number:
910-678-8611

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  95-01525 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 95-01525 , 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: 890134J , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0134J . This is a "BLUE CROSS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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