Provider Demographics
NPI:1083600720
Name:BEACHCARE URGENT MEDICAL CARE CENTER OF HAVELOCK
Entity Type:Organization
Organization Name:BEACHCARE URGENT MEDICAL CARE CENTER OF HAVELOCK
Other - Org Name:BEACHCARE OF HAVELOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:252-447-7474
Mailing Address - Street 1:1224 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-2405
Mailing Address - Country:US
Mailing Address - Phone:252-447-7474
Mailing Address - Fax:252-447-1050
Practice Address - Street 1:1224 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2405
Practice Address - Country:US
Practice Address - Phone:252-447-7474
Practice Address - Fax:252-447-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39759261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344612AMedicaid
NC0138BOtherBLUE CROSS BLUE SHIELD
NC344612CMedicaid
NCD94044Medicare UPIN
NC343973Medicare Oscar/Certification
NC344612AMedicaid