Basic Information
| Provider Information | |||||||||
| NPI: | 1295881068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDHILLS HEART SURGERY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3419 MELROSE ROAD | ||||||||
| Address2: | A | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283041608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103239922 | ||||||||
| FaxNumber: | 9103239501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3419 MELROSE ROAD | ||||||||
| Address2: | A | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283041608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103239922 | ||||||||
| FaxNumber: | 9103239501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FIETSAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEART SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 9103239922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 111444 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8931917 | 05 | NC | MEDICAID |