Basic Information
| Provider Information | |||||||||
| NPI: | 1821266180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW HANOVER REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC SPECIALTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22131 S. 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284019000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 02/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BURDEN | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT FIN. SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9108155228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 012AP | 01 | NC | BCBSNC | OTHER | 89012AP | 05 | NC | MEDICAID |