Provider Demographics
NPI:1164557567
Name:GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:GCDPH ADULT IMMUNIZATION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HARVETTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-641-7777
Mailing Address - Street 1:1100 E WENDOVER AVE
Mailing Address - Street 2:ADULT IMMUNIZATION ADMINISTRATION
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6713
Mailing Address - Country:US
Mailing Address - Phone:336-647-1777
Mailing Address - Fax:336-641-6971
Practice Address - Street 1:501 E GREEN DR
Practice Address - Street 2:ADULT IMMUNIZATION SERVICES
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260-6707
Practice Address - Country:US
Practice Address - Phone:336-845-7990
Practice Address - Fax:336-845-7987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X, 261QM2500X, 261QP0905X, 3336C0002X
NC34D0238958291U00000X
NC34D0664205291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-07677OtherUHC
07124OtherBCBS
AS34604210001OtherCIGNA HEALTHCARE