Basic Information
| Provider Information | |||||||||
| NPI: | 1942267042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPITAL ORTHOPAEDIC AND SPORTS MEDICINE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAROLINA REHABILITATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276199248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198768302 | ||||||||
| FaxNumber: | 9198769690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 DRESSER CT | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198768302 | ||||||||
| FaxNumber: | 9198769690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENEDICT | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198768300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 32339 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 890143H | 05 | NC | MEDICAID | CC7654 | 01 | NC | RAILROAD MEDICARE | OTHER |