Basic Information
| Provider Information | |||||||||
| NPI: | 1366636789 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SYLVAN VALLEY OB/GYN, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287123874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288848860 | ||||||||
| FaxNumber: | 8288857164 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287123874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288848860 | ||||||||
| FaxNumber: | 8288857164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 08/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | CARMELO | ||||||||
| AuthorizedOfficialMiddleName: | ABEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8288848860 | ||||||||
| 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 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 012PR | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 89012PR | 05 | NC | MEDICAID |