Basic Information
Provider Information | |||||||||
NPI: | 1659640761 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOLDSBORO ORTHOPEDICS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOLDSBORO ORTHPAEDIC ASSOCIATES, P.A, | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1717 | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275331717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195874081 | ||||||||
FaxNumber: | 9195870775 | ||||||||
Practice Location | |||||||||
Address1: | 2808 MCLAMB PL | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275341600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195874081 | ||||||||
FaxNumber: | 9195870775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2011 | ||||||||
LastUpdateDate: | 12/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMAS | ||||||||
AuthorizedOfficialFirstName: | CLYDE | ||||||||
AuthorizedOfficialMiddleName: | LOUIS | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9195874081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WAYNE HEALTH PHYSICIANS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.