Basic Information
| Provider Information | |||||||||
| NPI: | 1831249986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF CUMBERLAND | ||||||||
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| OtherOrganizationName: | CUMBERLAND CO HLT DPT CLINICAL SVS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 RAMSEY STREET | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333600 | ||||||||
| FaxNumber: | 9103217103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 RAMSEY STREET | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333600 | ||||||||
| FaxNumber: | 9103217103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9104333719 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF CUMBERLAND | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LX0001X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 251B00000X | NC | N | Agencies | Case Management | 261Q00000X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | 261QD0000X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0050X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QM2500X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QP0905X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | 261QP2300X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 291U00000X | NC | N | Laboratories | Clinical Medical Laboratory | 363AM0700X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LP0200X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 251K00000X | NC | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 3403056 | 05 | NC | MEDICAID | 3404429 | 05 | NC | MEDICAID | 0705C | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |