Provider Demographics
NPI:1093982605
Name:PELICAN FAMILY MEDICINE, P.A.
Entity Type:Organization
Organization Name:PELICAN FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SAMUEL THOMAS
Authorized Official - Last Name:ARMITAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-792-1001
Mailing Address - Street 1:14057 US HIGHWAY 17 N STE 220
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-3779
Mailing Address - Country:US
Mailing Address - Phone:910-821-1197
Mailing Address - Fax:910-821-1187
Practice Address - Street 1:14057 US HIGHWAY 17 N STE 220
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-3779
Practice Address - Country:US
Practice Address - Phone:910-821-1197
Practice Address - Fax:910-821-1187
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PELICAN FAMILY MEDICINE, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-13
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903907Medicaid
NC2294885AMedicare PIN
NC5903907Medicaid