Basic Information
| Provider Information | |||||||||
| NPI: | 1164462586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY MEDICINE PHYSICIANS OF CRAVEN COUNTY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 DRESSLER RD NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934443 | ||||||||
| FaxNumber: | 3304938677 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285603452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934443 | ||||||||
| FaxNumber: | 3304938677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | PACKO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3304934443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | QPA506 | 05 | SC | MEDICAID | 890285Q | 05 | NC | MEDICAID |