Basic Information
| Provider Information | |||||||||
| NPI: | 1699921999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWAY MEDICAL CENTER-CANTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1409 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287161409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286460080 | ||||||||
| FaxNumber: | 8286460580 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287163805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286460080 | ||||||||
| FaxNumber: | 8286460580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | FREEMAN | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8286272211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDWAY MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 62447 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4245150001 | 01 | NC | MEDICARE DME | OTHER | 5900304 | 05 | NC | MEDICAID | C17128 | 01 | NC | RR MEDICARE | OTHER |