Basic Information
Provider Information | |||||||||
NPI: | 1295923662 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | URGENT CARE OF CARY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 935 SHOTWELL RD | ||||||||
Address2: | SUITE 108 | ||||||||
City: | CLAYTON | ||||||||
State: | NC | ||||||||
PostalCode: | 27520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195500821 | ||||||||
FaxNumber: | 9195500735 | ||||||||
Practice Location | |||||||||
Address1: | 3420 TEN-TEN RD | ||||||||
Address2: | SUITE 318 | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 27518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193625871 | ||||||||
FaxNumber: | 9193625874 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2007 | ||||||||
LastUpdateDate: | 08/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REEVES | ||||||||
AuthorizedOfficialFirstName: | NENA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS DEVELOPMENT | ||||||||
AuthorizedOfficialTelephone: | 9195500821 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 97301201 | 01 | NC | AETNA | OTHER | 5909119 | 05 | NC |   | MEDICAID | 020AE | 01 | NC | BCBS | OTHER |