Basic Information
| Provider Information | |||||||||
| NPI: | 1457403479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEHURST GERIATRICS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
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| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283743290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102956158 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 BLAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102956158 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 02/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | PATRICK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | WARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9102956158 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890187F | 05 | NC | MEDICAID | 0187F | 01 | NC | BCBS | OTHER |