Basic Information
| Provider Information | |||||||||
| NPI: | 1477538254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORT HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | PORT HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300-110 SAPPHIRE COURT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2602 COURTIER DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527573172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAVIDGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | OLIVER | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2528307540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | MHL-074-145 | NC | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 101Y00000X | MHL-074-157 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 6005592 | 05 | NC | MEDICAID | 6603789 | 05 | NC | MEDICAID | 6005332 | 05 | NC | MEDICAID | 6005597 | 05 | NC | MEDICAID | 6603790 | 05 | NC | MEDICAID | 016X5 | 01 | NC | BCBS PROVIDER NUMBER | OTHER | 6005329 | 05 | NC | MEDICAID | 5900726 | 05 | NC | MEDICAID | 6005334 | 05 | NC | MEDICAID | 5900727 | 05 | NC | MEDICAID |