Basic Information
Provider Information | |||||||||
NPI: | 1245500909 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PORT HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORT HUMAN SERVICES | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300-110 SAPPHIRE COURT | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 27834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528307540 | ||||||||
FaxNumber: | 2524130932 | ||||||||
Practice Location | |||||||||
Address1: | 2808 CROATAN HWY SUITE B | ||||||||
Address2: |   | ||||||||
City: | NAGS HEAD | ||||||||
State: | NC | ||||||||
PostalCode: | 279599024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524412324 | ||||||||
FaxNumber: | 2524411994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2012 | ||||||||
LastUpdateDate: | 02/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAVIDGE | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | OLIVER | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2528307540 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL-028-018 | NC | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.