Basic Information
Provider Information | |||||||||
NPI: | 1376951814 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL CAROLINA PHYSICIANS - SANDHILLS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY HEALTH ASSOCIATES OF SANFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 742694 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303742694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197751000 | ||||||||
FaxNumber: | 9197753377 | ||||||||
Practice Location | |||||||||
Address1: | 1911 K M WICKER MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | SANFORD | ||||||||
State: | NC | ||||||||
PostalCode: | 273305070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197751000 | ||||||||
FaxNumber: | 9197753377 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2014 | ||||||||
LastUpdateDate: | 05/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JAMES | ||||||||
AuthorizedOfficialFirstName: | WESLEY | ||||||||
AuthorizedOfficialMiddleName: | O. | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL CFO, TENET | ||||||||
AuthorizedOfficialTelephone: | 4042655009 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.