Basic Information
| Provider Information | |||||||||
| NPI: | 1215931589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CFVHS ED PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106156448 | ||||||||
| FaxNumber: | 9106155070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 OWEN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106158780 | ||||||||
| FaxNumber: | 9103216250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HULLENDER | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CORP REVENUE CYCLE SYSTEM | ||||||||
| AuthorizedOfficialTelephone: | 9106153450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89015CK | 05 | NC | MEDICAID | 015CK | 01 | NC | CFVHS' GROUP BCBS NC # | OTHER |