Provider Demographics
NPI:1245218940
Name:BETHLEHEM FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:BETHLEHEM FAMILY PRACTICE, PA
Other - Org Name:MARK A. FARUQUE MD PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:FARUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-495-8226
Mailing Address - Street 1:PO BOX 6306
Mailing Address - Street 2:BETHLEHEM STATION
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-6403
Mailing Address - Country:US
Mailing Address - Phone:828-495-8226
Mailing Address - Fax:828-495-4191
Practice Address - Street 1:174 BOLICK LN
Practice Address - Street 2:SUITE 202
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-3319
Practice Address - Country:US
Practice Address - Phone:828-495-8226
Practice Address - Fax:828-495-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33651261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC348918CMedicaid
NC0238UOtherBCBS
NC348918AMedicaid
NC348918Medicare PIN
NC0238UOtherBCBS
E07099Medicare UPIN
NC348918CMedicaid