Provider Demographics
NPI:1235283847
Name:MARTIN TYRRELL WASHINGTON DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:MARTIN TYRRELL WASHINGTON DISTRICT HEALTH DEPARTMENT
Other - Org Name:TYRRELL COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-793-3023
Mailing Address - Street 1:198 NC HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NC
Mailing Address - Zip Code:27962-9232
Mailing Address - Country:US
Mailing Address - Phone:252-793-3023
Mailing Address - Fax:252-791-3159
Practice Address - Street 1:198 NC HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962-9232
Practice Address - Country:US
Practice Address - Phone:252-793-3023
Practice Address - Fax:252-791-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X, 261QF0050X, 261QH0100X, 261QM2500X, 261QP0905X, 261QP2300X, 291U00000X
NC044413336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404389Medicaid