Provider Demographics
NPI:1356665152
Name:CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC
Entity Type:Organization
Organization Name:CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC
Other - Org Name:CONVENIENT CARE FOR HOKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-615-6700
Mailing Address - Street 1:PO BOX 40908
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-0908
Mailing Address - Country:US
Mailing Address - Phone:910-615-6448
Mailing Address - Fax:910-615-5070
Practice Address - Street 1:104 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3218
Practice Address - Country:US
Practice Address - Phone:910-615-3140
Practice Address - Fax:910-486-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913981Medicaid
NC2347881Medicare PIN