Basic Information
| Provider Information | |||||||||
| NPI: | 1548226004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND COUNTY HOSPITAL SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FERNCREEK GENERAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 FERNCREEK DR | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104853880 | ||||||||
| FaxNumber: | 9104855341 | ||||||||
| Practice Location | |||||||||
| Address1: | 4140 FERNCREEK DR | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104853880 | ||||||||
| FaxNumber: | 9104855341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERSON | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9104853880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CAPPM, CMC,CMOM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 122131 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 89015VX | 05 | NC | MEDICAID |