Basic Information
| Provider Information | |||||||||
| NPI: | 1144268798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDHILLS HEART SURGERY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3193 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277153193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446318 | ||||||||
| FaxNumber: | 9195446336 | ||||||||
| Practice Location | |||||||||
| Address1: | 3419A MELROSE RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283041608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103239922 | ||||||||
| FaxNumber: | 9103239501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FIETSAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9103239922 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 5902973 | 05 | NC | MEDICAID | 017RP | 01 | NC | BCBS-NC GROUP | OTHER |