Basic Information
| Provider Information | |||||||||
| NPI: | 1962404384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGIONAL DIABETES AND ENDOCRINE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106156448 | ||||||||
| FaxNumber: | 9106155070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ROBESON ST | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283015552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106151623 | ||||||||
| FaxNumber: | 9103216248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | FISER | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CORPORATE REVEUNE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 9106155572 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H0213 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89104UR | 05 | NC | MEDICAID |