Basic Information
| Provider Information | |||||||||
| NPI: | 1104220300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LENOIR PHYSICIANS NETWORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LENOIR NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 DOCTORS DR | ||||||||
| Address2: | SUITE G | ||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285011589 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 DOCTORS DR | ||||||||
| Address2: | SUITE E2 | ||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285011589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525224446 | ||||||||
| FaxNumber: | 2525224484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2014 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525227000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LENOIR PHYSICIANS NETWORK LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1104220300 | 05 | NC | MEDICAID |