Basic Information
| Provider Information | |||||||||
| NPI: | 1497827794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN CAROLINA INTERNAL MEDICINE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13187 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285613187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526361919 | ||||||||
| FaxNumber: | 2526362656 | ||||||||
| Practice Location | |||||||||
| Address1: | 2604 DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526361919 | ||||||||
| FaxNumber: | 2526362656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOLTON | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2526331010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | REGISTRATION39206 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 890235U | 05 | NC | MEDICAID | 01907 | 01 | NC | BCBS NC | OTHER |