Provider Demographics
NPI:1215184924
Name:FAYETTEVILLE ORTHOPAEDIC CLINIC, PA
Entity Type:Organization
Organization Name:FAYETTEVILLE ORTHOPAEDIC CLINIC, PA
Other - Org Name:FAYETTEVILLE ORTHOPAEDICS & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRAT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACEJKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-223-2007
Mailing Address - Street 1:300 E. MCKAY STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-9037
Mailing Address - Country:US
Mailing Address - Phone:910-484-3114
Mailing Address - Fax:910-484-8824
Practice Address - Street 1:300 E. MCKAY STREET
Practice Address - Street 2:SUITE E
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9037
Practice Address - Country:US
Practice Address - Phone:910-484-3114
Practice Address - Fax:910-484-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901555Medicaid
NC0295Medicare PIN
NC0314090001Medicare NSC