Basic Information
| Provider Information | |||||||||
| NPI: | 1548535107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH CAROLINA ELDERLY PSYCHIATRIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 606 WADE AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194432360 | ||||||||
| FaxNumber: | 9198003039 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 WADE AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194432360 | ||||||||
| FaxNumber: | 9198003039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2012 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | MANGANO | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9194432360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.