Provider Demographics
NPI:1306855770
Name:HALIFAX GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:HALIFAX GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFF MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PADMA
Authorized Official - Middle Name:DEVI
Authorized Official - Last Name:YERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-535-6478
Mailing Address - Street 1:1007 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-6451
Mailing Address - Country:US
Mailing Address - Phone:252-535-6478
Mailing Address - Fax:252-535-6483
Practice Address - Street 1:1007 GREGORY DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-6451
Practice Address - Country:US
Practice Address - Phone:252-535-6478
Practice Address - Fax:252-535-6483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700163207RG0100X
NCAS0141261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0167JOtherBCBS
NC891068EMedicaid
NC2235302BMedicare PIN
NC0167JOtherBCBS