Provider Demographics
NPI:1669421608
Name:CENTRAL CAROLINA PODIATRY PA
Entity type:Organization
Organization Name:CENTRAL CAROLINA PODIATRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:W
Authorized Official - Last Name:IREDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-477-9333
Mailing Address - Street 1:4119 CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2153
Mailing Address - Country:US
Mailing Address - Phone:919-477-9333
Mailing Address - Fax:919-477-9389
Practice Address - Street 1:4119 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2153
Practice Address - Country:US
Practice Address - Phone:919-477-9333
Practice Address - Fax:919-477-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908034Medicaid
NC0264890001Medicare NSC
NC0710Medicare PIN