Basic Information
| Provider Information | |||||||||
| NPI: | 1346279445 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FHPG, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MONTGOMERY MEMORIAL HOSPITAL PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107151010 | ||||||||
| FaxNumber: | 9107151926 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ALLEN ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273712802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105715000 | ||||||||
| FaxNumber: | 9107151926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 01/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | DEJACO | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9107151913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 89014CM | 05 | NC | MEDICAID | BCBS | 01 | NC | BCBS OF NC GROUP NUMBER | OTHER |