Basic Information
| Provider Information | |||||||||
| NPI: | 1245219799 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACT MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 696 | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 311-4E JUDGES RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | BEEKMAN | ||||||||
| AuthorizedOfficialFirstName: | ERINN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107916767 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 174400000X | 87550 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 016UG | 01 | NC | BCBSNC PRIMARY CARE ONLY | OTHER | 0706G | 01 | NC | BCBSNC MENTAL HEALTH ONLY | OTHER | 890706G | 05 | NC | MEDICAID | 6005401 | 05 | NC | MEDICAID | CI3714 | 01 | NC | RAILROAD MEDICARE | OTHER | 20992 | 01 | NC | PIEDMONT BEHAVIORAL HEALT | OTHER | E698 | 01 | NC | PARTNERS | OTHER |