Basic Information
| Provider Information | |||||||||
| NPI: | 1184750150 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAMPSON REGIONAL MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | SAMPSON COUNTY MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 BEAMAN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283282603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105928511 | ||||||||
| FaxNumber: | 9105925461 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 BEAMAN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283282603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105928511 | ||||||||
| FaxNumber: | 9105925461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEINZMAN | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9105928511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H0067 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3405259 | 05 | NC | MEDICAID | 0086B | 01 | NC | BC | OTHER |