Basic Information
| Provider Information | |||||||||
| NPI: | 1376519512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRAVEN PATHOLOGY ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100559 | ||||||||
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| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436644300 | ||||||||
| FaxNumber: | 8436644308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 NEUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285603449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526379298 | ||||||||
| FaxNumber: | 2526338941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | BENNERT | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | WILKINSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2526338069 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 36652 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0104X | 30691 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology | 207ZP0102X | 36652 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 7901078 | 05 | NC | MEDICAID | 01078 | 01 | NC | BCBS | OTHER |