Basic Information
Provider Information | |||||||||
NPI: | 1538147715 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EAST CAROLINA HEALTH - CHOWAN INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VIDANT CHOWAN HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 629 | ||||||||
Address2: |   | ||||||||
City: | EDENTON | ||||||||
State: | NC | ||||||||
PostalCode: | 279320629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524828451 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 211 VIRGINIA RD | ||||||||
Address2: |   | ||||||||
City: | EDENTON | ||||||||
State: | NC | ||||||||
PostalCode: | 279329668 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524828451 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2006 | ||||||||
LastUpdateDate: | 02/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SACKRISON | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | N. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2524826268 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EAST CAROLINA HEALTH - CHOWAN INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H0063 | NC | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 3415033 | 05 | NC |   | MEDICAID | 3416008 | 05 | NC |   | MEDICAID | 0084D | 01 | NC | BCBS SNF # | OTHER |