Provider Demographics
NPI:1205865979
Name:EDGEWATER MEDICAL CENTER AND URGENT
Entity Type:Organization
Organization Name:EDGEWATER MEDICAL CENTER AND URGENT
Other - Org Name:EDGEWATER MEDICAL CENTER AND URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:C
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-893-4111
Mailing Address - Street 1:100 S 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-6690
Mailing Address - Country:US
Mailing Address - Phone:910-893-4111
Mailing Address - Fax:910-893-9850
Practice Address - Street 1:100 S 10TH STREET
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6690
Practice Address - Country:US
Practice Address - Phone:910-893-4111
Practice Address - Fax:910-893-9850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWATER MEDICAL CENTER AND URGENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5696450001Medicare NSC
NC2321413Medicare PIN