Provider Demographics
NPI:1295715076
Name:LONG BEACH FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:LONG BEACH FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:910-278-3500
Mailing Address - Street 1:2006 ROBERT RUARK DR
Mailing Address - Street 2:S E
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-2652
Mailing Address - Country:US
Mailing Address - Phone:910-457-0595
Mailing Address - Fax:
Practice Address - Street 1:4700 E OAK ISLAND DR
Practice Address - Street 2:SUITE F
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-5200
Practice Address - Country:US
Practice Address - Phone:910-278-3500
Practice Address - Fax:910-278-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0039512173000000X
NC39512261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC207Q00000XOtherMEDICARE TAXOMONY
NC207Q00000XOtherMEDICAID TAXOMONY
NC8943093Medicaid
NC207Q00000XOtherMEDICARE TAXOMONY
NC2221964EMedicare PIN