Provider Demographics
NPI:1356845309
Name:UNIVERSITY OF NORTH CAROLINA AT PEMBROKE STUDENT HEALTH SERVICES
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTH CAROLINA AT PEMBROKE STUDENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CHANCELLOR FOR STUDENT AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHAEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-521-6175
Mailing Address - Street 1:P.O. BOX 1510
Mailing Address - Street 2:ONE UNIVERSITY DRIVE
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1510
Mailing Address - Country:US
Mailing Address - Phone:910-521-6219
Mailing Address - Fax:910-521-6549
Practice Address - Street 1:113 HAWK DRIVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-1510
Practice Address - Country:US
Practice Address - Phone:910-521-6219
Practice Address - Fax:910-521-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC183091207QA0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty