Basic Information
Provider Information | |||||||||
NPI: | 1063469179 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIAC THORACIC & VASCULAR ASSOCIATES OF EASTERN CAROLINA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 960 NEWMAN RD | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285625200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526336730 | ||||||||
FaxNumber: | 2526336740 | ||||||||
Practice Location | |||||||||
Address1: | 960 NEWMAN RD | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 28562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526336730 | ||||||||
FaxNumber: | 2526336740 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 12/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALLIGAN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | EDWARD | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2526336730 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 9700577 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 018CH | 01 | NC | BCBS | OTHER | 5904329 | 05 | NC |   | MEDICAID |