Basic Information
| Provider Information | |||||||||
| NPI: | 1780074385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND COUNTY DEPT OF PUBLIC HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333719 | ||||||||
| FaxNumber: | 9103217103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333719 | ||||||||
| FaxNumber: | 9103217103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | GELIN | ||||||||
| AuthorizedOfficialFirstName: | COLETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 91043337199 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 7896 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 3403056 | 05 | NC | MEDICAID | 004 | 01 | NC | TRICARE | OTHER | 3404429 | 05 | NC | MEDICAID | 0705C | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |