Basic Information
Provider Information | |||||||||
NPI: | 1679745434 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEACHCARE EAST URGENT MEDICAL CENTER PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 PROFESSIONAL PARK DR STE D | ||||||||
Address2: |   | ||||||||
City: | BEAUFORT | ||||||||
State: | NC | ||||||||
PostalCode: | 285162464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527282205 | ||||||||
FaxNumber: | 2527283248 | ||||||||
Practice Location | |||||||||
Address1: | 5059 HWY 70 W | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD CITY | ||||||||
State: | NC | ||||||||
PostalCode: | 285574503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528083696 | ||||||||
FaxNumber: | 2528082022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2008 | ||||||||
LastUpdateDate: | 05/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | JEFFERY | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2528083696 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 39759 | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.