Basic Information
Provider Information | |||||||||
NPI: | 1902101496 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PORT HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORT HUMAN SERVICES | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300-110 SAPPHIRE COURT | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 27834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2528307540 | ||||||||
FaxNumber: | 2524130932 | ||||||||
Practice Location | |||||||||
Address1: | 1507 MARTIN STREET | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284016422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102544817 | ||||||||
FaxNumber: | 9102518933 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2011 | ||||||||
LastUpdateDate: | 04/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROUNTREE | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: | WARD | ||||||||
AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2528307540 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.