Basic Information
| Provider Information | |||||||||
| NPI: | 1003857319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA VASCULAR INSTITUTE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2493 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277152493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446318 | ||||||||
| FaxNumber: | 9195446336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 OLIVER ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108226587 | ||||||||
| FaxNumber: | 9104266587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROULHAC | ||||||||
| AuthorizedOfficialFirstName: | MAURICE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9108226587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | DB8445 | 01 | NC | RAILROAD MEDICARE | OTHER | 8973468 | 05 | NC | MEDICAID |