Basic Information
| Provider Information | |||||||||
| NPI: | 1194055996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PBL HEALTHCARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3121 WINESAP RD | ||||||||
| Address2: | |||||||||
| City: | HOPE MILLS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283488357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106442280 | ||||||||
| FaxNumber: | 9104858832 | ||||||||
| Practice Location | |||||||||
| Address1: | 514 BEAUMONT RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104858831 | ||||||||
| FaxNumber: | 9104858832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2009 | ||||||||
| LastUpdateDate: | 12/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | BUI | ||||||||
| AuthorizedOfficialFirstName: | BAO-ANH | ||||||||
| AuthorizedOfficialMiddleName: | NGOC | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9106442280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2009-01251 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.