Provider Demographics
NPI:1225459431
Name:SANDHILLS PHYSICIAN OF MENTAL HEALTH CLINIC, PLLC
Entity Type:Organization
Organization Name:SANDHILLS PHYSICIAN OF MENTAL HEALTH CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRITZ
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-491-2636
Mailing Address - Street 1:4155 FERNCREEK DR
Mailing Address - Street 2:SUITE 102 A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2581
Mailing Address - Country:US
Mailing Address - Phone:910-491-2636
Mailing Address - Fax:
Practice Address - Street 1:4155 FERNCREEK DR
Practice Address - Street 2:SUITE 102 A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2581
Practice Address - Country:US
Practice Address - Phone:910-491-2636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-004462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC57205Medicaid