Basic Information
| Provider Information | |||||||||
| NPI: | 1033430475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND COUNTY HOSPITAL SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPE FEAR VALLEY UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106156448 | ||||||||
| FaxNumber: | 9106155070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 ROBESON ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106153220 | ||||||||
| FaxNumber: | 9104862170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | NAGOWSKI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9106156700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | H0213 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NC | MEDICAID |