Basic Information
| Provider Information | |||||||||
| NPI: | 1366753741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRSTHEALTH OF THE CAROLINAS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIRSTHEALTH RICHMOND MEDICAL GROUP - ORTHOPEDIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4970 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662657922 | ||||||||
| FaxNumber: | 6174021099 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 S LONG DR | ||||||||
| Address2: | SUITE K | ||||||||
| City: | ROCKINGHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283794318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104174090 | ||||||||
| FaxNumber: | 9108951550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | DEJACO | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9107151913 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207X00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5915191 | 05 | NC | MEDICAID |