Basic Information
| Provider Information | |||||||||
| NPI: | 1508829003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE FEAR NEUROLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87049 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283047049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232247 | ||||||||
| FaxNumber: | 9104868064 | ||||||||
| Practice Location | |||||||||
| Address1: | 2135 VALLEYGATE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232247 | ||||||||
| FaxNumber: | 9104868064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHARYA | ||||||||
| AuthorizedOfficialFirstName: | SAMPATH | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9103232247 | ||||||||
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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 | 174400000X | 9700897 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890171P | 05 | NC | MEDICAID | COMMERICAL | 01 | NC | GROUP NUMBER | OTHER |