Basic Information
| Provider Information | |||||||||
| NPI: | 1538127121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH STATE MEDICAL CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 PROFESSIONAL DR | ||||||||
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| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365999257 | ||||||||
| FaxNumber: | 3365992716 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365999257 | ||||||||
| FaxNumber: | 3365992716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | GODWIN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3365999257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02948 | 01 | NC | BCBS/NC | OTHER | 5911497 | 05 | NC | MEDICAID |