Provider Demographics
NPI:1114111630
Name:CAROLINA ORTHOPEDIC AND SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:CAROLINA ORTHOPEDIC AND SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-634-2676
Mailing Address - Street 1:738 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5238
Mailing Address - Country:US
Mailing Address - Phone:252-634-2676
Mailing Address - Fax:252-633-3502
Practice Address - Street 1:925 E MAIN ST
Practice Address - Street 2:SUITE 50
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2374
Practice Address - Country:US
Practice Address - Phone:252-634-2676
Practice Address - Fax:252-633-3502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA ORTHOPEDIC AND SPORTS MEDICINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-28
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC142144207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908528Medicaid
NC019K4OtherBCBS
NC047H3OtherBCBS DME
NC019K4OtherBCBS
NC5908528Medicaid
NCDG6566Medicare PIN