Basic Information
Provider Information | |||||||||
NPI: | 1801010293 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARNES | ||||||||
FirstName: | LARRY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 325 WESTERN BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285466341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9105771555 | ||||||||
FaxNumber: | 9105771841 | ||||||||
Practice Location | |||||||||
Address1: | 325 WESTERN BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285466341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9105771555 | ||||||||
FaxNumber: | 9105771841 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | 26184 | NC | Y |   | Emergency Medical Service Providers | Emergency Medical Technician, Basic |   |
ID Information
ID | Type | State | Issuer | Description | 8913111 | 05 | NC |   | MEDICAID | 13111 | 01 | NC | BCBS | OTHER |