Basic Information
| Provider Information | |||||||||
| NPI: | 1275096497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOOFI | ||||||||
| FirstName: | MADIHA | ||||||||
| MiddleName: | EMRAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 MOYE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278344300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527442803 | ||||||||
| FaxNumber: | 2527443616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2019 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 2019-00909 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 2019-00909 | NC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | NN6849A | 01 | NC | MEDICARE | OTHER | 1275096497 | 05 | NC | MEDICAID | 2019-00909 | 01 | NC | NORTH CAROLINA MEDICAL BOARD LICENSE | OTHER | 201W9 | 01 | NC | BCBS OF NC | OTHER |