Basic Information
Provider Information | |||||||||
NPI: | 1710492871 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARTERET SURGICAL ASSOCIATES P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAROLINAS CENTER FOR SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3714 GUARDIAN AVE STE E | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD CITY | ||||||||
State: | NC | ||||||||
PostalCode: | 285572975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522225862 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2145 COUNTRY CLUB RD STE 800 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285462400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109395759 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2017 | ||||||||
LastUpdateDate: | 12/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WATSON | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | JACOB | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALIST | ||||||||
AuthorizedOfficialTelephone: | 2522225862 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CARTERET SURGICAL ASSOCIATES P.A. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.