Basic Information
| Provider Information | |||||||||
| NPI: | 1275735425 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSTON HEALTH SERVICES CORPORATION | ||||||||
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| OtherOrganizationName: | JOHNSTON MEMORIAL HOSPITAL AUTHORITY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 N BRIGHTLEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 N BRIGHTLEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 05/02/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | ALVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9199387128 | ||||||||
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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 | 367500000X | H0151 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.