Basic Information
| Provider Information | |||||||||
| NPI: | 1750835336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH CAROLINA NEPHROLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3031 NEW BERN AVE | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276102989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192313966 | ||||||||
| FaxNumber: | 9192313912 | ||||||||
| Practice Location | |||||||||
| Address1: | 3031 NEW BERN AVE | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276102989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192313966 | ||||||||
| FaxNumber: | 9192313912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2016 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | FONTENOT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9192313966 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.