Basic Information
Provider Information | |||||||||
NPI: | 1558327726 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PERSON EMERGENCY PHYSICANS PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 30727 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282300727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432373378 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Practice Location | |||||||||
Address1: | 615 RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | ROXBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275734629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432373378 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 03/17/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YARBOROUGH | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8432373378 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 790104J | 05 | NC |   | MEDICAID | 0104J | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | CN7197 | 01 | NC | RAILROAD MEDICARE | OTHER |