Basic Information
| Provider Information | |||||||||
| NPI: | 1417914722 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBESON HEALTH CARE CORPORATION | ||||||||
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| OtherOrganizationName: | SOUTH ROBESON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 COMMERCE PLZ | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212900 | ||||||||
| FaxNumber: | 9107759165 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 S WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106286711 | ||||||||
| FaxNumber: | 9106285735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | TIMOTHY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9105212900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MHL-078-063 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344570 A/C | 05 | NC | MEDICAID | 6005792 | 05 | NC | MEDICAID |