Basic Information
| Provider Information | |||||||||
| NPI: | 1952360331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOMBENGER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 201 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044873131 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044873131 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 16518 | 01 | NC | BLUE CROSS | OTHER | 8916518 | 05 | NC | MEDICAID |