Provider Demographics
NPI:1366779928
Name:EASTOVER OBSTETRICS AND GYNECOLOGY ASSOCIATES INC
Entity type:Organization
Organization Name:EASTOVER OBSTETRICS AND GYNECOLOGY ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:7810 PROVIDENCE RD
Practice Address - Street 2:STE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2954
Practice Address - Country:US
Practice Address - Phone:704-446-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTOVER OBSTETRICS AND GYNECOLOGY ASSOCIATES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-03
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902970Medicaid
NC1366779928Medicaid
SCNPB369Medicaid
NC1366779928Medicaid