Provider Demographics
NPI:1134460892
Name:OBXMD, P.C.
Entity Type:Organization
Organization Name:OBXMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUPAN-MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-256-7792
Mailing Address - Street 1:4721 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-8912
Mailing Address - Country:US
Mailing Address - Phone:252-256-7792
Mailing Address - Fax:
Practice Address - Street 1:4721 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-8912
Practice Address - Country:US
Practice Address - Phone:252-256-7792
Practice Address - Fax:252-256-7691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01853261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care