Provider Demographics
NPI:1225367253
Name:EASTERN NORTH CAROLINA MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:EASTERN NORTH CAROLINA MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-451-2700
Mailing Address - Street 1:PO BOX 7867
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0867
Mailing Address - Country:US
Mailing Address - Phone:252-451-2700
Mailing Address - Fax:252-243-0599
Practice Address - Street 1:1812 GLENDALE DR SW
Practice Address - Street 2:SUITE B
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4676
Practice Address - Country:US
Practice Address - Phone:252-291-3100
Practice Address - Fax:252-243-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011C5Medicaid
NC011C5OtherBCBS GROUP ID#
NC89011C5Medicaid
NC2344492Medicare PIN