Basic Information
| Provider Information | |||||||||
| NPI: | 1518063064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE HEART CENTER, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 ROBESON ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844100 | ||||||||
| FaxNumber: | 9104844179 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 ROBESON ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844100 | ||||||||
| FaxNumber: | 9104844179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | JESSICCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9104844100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890146Y | 05 | NC | MEDICAID |