Basic Information
| Provider Information | |||||||||
| NPI: | 1679763593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSTON MEMORIAL HOSPITAL AUTHORITY | ||||||||
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| OtherOrganizationName: | JOHNSTON MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1376 | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275771376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 N BRIGHTLEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 08/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | PARHAM | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9199387155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | H0151 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 017J5 | 01 | NC | BCBS | OTHER |