Basic Information
| Provider Information | |||||||||
| NPI: | 1275566283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PURDUM | ||||||||
| FirstName: | PRESTON | ||||||||
| MiddleName: | PEMBERTON | ||||||||
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| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11301 CARMEL COMMONS BLVD | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282265305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043728201 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BILLINGSLEY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043725166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 9500190 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 8969467 | 05 | NC | MEDICAID |