Basic Information
| Provider Information | |||||||||
| NPI: | 1295745099 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSTON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JOHNSTON FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N ENGLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | KENLY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275429290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192844149 | ||||||||
| FaxNumber: | 9192846008 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N ENGLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | KENLY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275429290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192844149 | ||||||||
| FaxNumber: | 9192846008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOODBRIDGE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | VINCENT | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9192844149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 9900728 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 891207E | 05 | NC | MEDICAID |