Basic Information
| Provider Information | |||||||||
| NPI: | 1104009323 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRSTHEALTH OF THE CAROLINAS, INC | ||||||||
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| OtherOrganizationName: | FIRSTHEALTH CARDIOVASCULAR AND THORACIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843427 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022843427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107154111 | ||||||||
| FaxNumber: | 9107154101 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107154111 | ||||||||
| FaxNumber: | 9107154101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2007 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | DEJACO | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9107151913 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | NPB284 | 05 | SC | MEDICAID | 020CX | 01 | NC | BCBS | OTHER | 5908772 | 05 | NC | MEDICAID |