Provider Demographics
NPI:1003057696
Name:EASTERN CAROLINA GERIATRIC ASSOCIATES AND FAMILY CARE CENTER PLLC
Entity Type:Organization
Organization Name:EASTERN CAROLINA GERIATRIC ASSOCIATES AND FAMILY CARE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-332-6484
Mailing Address - Street 1:105 COMMERCE STREET
Mailing Address - Street 2:PO BOX 40
Mailing Address - City:POWELLSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27967
Mailing Address - Country:US
Mailing Address - Phone:252-332-6484
Mailing Address - Fax:252-332-1660
Practice Address - Street 1:105 COMMERCE STREET
Practice Address - Street 2:
Practice Address - City:POWELLSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27967-0040
Practice Address - Country:US
Practice Address - Phone:252-332-6484
Practice Address - Fax:252-332-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8931664Medicaid