Basic Information
Provider Information | |||||||||
NPI: | 1063808046 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEATHCOTE | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | SR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEATHCOTE | ||||||||
OtherFirstName: | SAMUEL | ||||||||
OtherMiddleName: | ALLEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2000 | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283742000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102956831 | ||||||||
FaxNumber: | 9102950244 | ||||||||
Practice Location | |||||||||
Address1: | 5 FIRST VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283749495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102956831 | ||||||||
FaxNumber: | 9102950244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2015 | ||||||||
LastUpdateDate: | 06/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2020-00609 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.