Basic Information
| Provider Information | |||||||||
| NPI: | 1992871917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ECEP II PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTERN CAROLINA EMERGENCY PHYSICIANS II PA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102023363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5301 WRIGHTSVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | KEY | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9102023363 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5906010 | 05 | NC | MEDICAID | NPA863 | 05 | SC | MEDICAID | 01456 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 7901456 | 05 | NC | MEDICAID | CI9263 | 01 | NC | RAILROAD MEDICARE | OTHER |