Basic Information
| Provider Information | |||||||||
| NPI: | 1316298458 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMPSON REGIONAL PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAROLINA PAIN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 BEAMAN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283282603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105908755 | ||||||||
| FaxNumber: | 9105966106 | ||||||||
| Practice Location | |||||||||
| Address1: | 518 BEAMAN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283282602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105964288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALLTZGLIER | ||||||||
| AuthorizedOfficialFirstName: | HUNTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9105908755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 200301024 | NC | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00492 | 01 | NC | BCBS | OTHER |