Basic Information
| Provider Information | |||||||||
| NPI: | 1073661690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FASTMED PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 SHOTWELL RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195623155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 S. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195623155 | ||||||||
| FaxNumber: | 9195627401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | REEVES | ||||||||
| AuthorizedOfficialFirstName: | NENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 9195500821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 017H1 | 01 | NC | BCBS | OTHER | 5902449 | 05 | NC | MEDICAID | 7181794 | 01 | AETNA | OTHER |