Basic Information
| Provider Information | |||||||||
| NPI: | 1649237355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL CAROLINA CARDIOVASCULAR & THORACIC SURGICAL ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 N ROXBORO ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194794188 | ||||||||
| FaxNumber: | 9194794204 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 N ROXBORO ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194794188 | ||||||||
| FaxNumber: | 9194794204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARCICANO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9194794188 | ||||||||
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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 | 261Q00000X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 89012N | 05 | NC | MEDICAID | 0121N | 01 | NC | BCBS | OTHER |