Basic Information
| Provider Information | |||||||||
| NPI: | 1700864980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST CAROLINA HEALTH - CHOWAN INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIDANT CHOWAN HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 629 | ||||||||
| Address2: | |||||||||
| City: | EDENTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279320629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524828451 | ||||||||
| FaxNumber: | 2524826274 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 VIRGINIA RD | ||||||||
| Address2: | |||||||||
| City: | EDENTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279329668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524828451 | ||||||||
| FaxNumber: | 2524826274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 05/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARLITNER | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2524826175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST CAROLINA HEALTH - CHOWAN INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | H0063 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8000183 | 05 | NC | MEDICAID |