Provider Demographics
NPI:1225133408
Name:COTTLE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:COTTLE MEDICAL GROUP PA
Other - Org Name:ELIZABETHTOWN FAMILY PHYSICIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:COTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-862-2900
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0790
Mailing Address - Country:US
Mailing Address - Phone:910-641-0400
Mailing Address - Fax:910-642-5929
Practice Address - Street 1:103 S OWEN STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-2900
Practice Address - Fax:910-862-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7924670Medicaid
NC017XTOtherBCBS OF NC
NC7924670Medicaid
NC017XTOtherBCBS OF NC