Provider Demographics
NPI:1114100872
Name:MEDAC HEALTH SERVICES, PA
Entity Type:Organization
Organization Name:MEDAC HEALTH SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-452-1400
Mailing Address - Street 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-332-1072
Practice Address - Street 1:8115 MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-8427
Practice Address - Country:US
Practice Address - Phone:910-686-1972
Practice Address - Fax:910-332-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15811208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07651OtherBCBS
NCCC2877OtherRAILROAD MEDICARE
NCCC2877OtherRAILROAD MEDICARE
NC0529800003Medicare NSC