Basic Information
Provider Information | |||||||||
NPI: | 1205865987 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSAL MEDICAL ASSOCIATES, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNIVERSAL FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 S 10TH STREET | ||||||||
Address2: |   | ||||||||
City: | LILLINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 275466690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9108934111 | ||||||||
FaxNumber: | 9108939850 | ||||||||
Practice Location | |||||||||
Address1: | 3396 SIX FORKS RD | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276097233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197818897 | ||||||||
FaxNumber: | 9197824983 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 07/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYES | ||||||||
AuthorizedOfficialFirstName: | RODOLFO | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER OWNER | ||||||||
AuthorizedOfficialTelephone: | 9108934111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNIVERSAL MEDICAL ASSOCIATES PLLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 89016NV | 05 | NC |   | MEDICAID |