Basic Information
| Provider Information | |||||||||
| NPI: | 1174005789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORT HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 SAPPHIRE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278349079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Practice Location | |||||||||
| Address1: | 706 N THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284723428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2018 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANTHONY | ||||||||
| AuthorizedOfficialFirstName: | TOYETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPENSATION & BENEFITS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2528307561 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1477538254 | 05 | NC | MEDICAID |