Provider Demographics
NPI:1376049619
Name:VIDANT MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:VIDANT MEDICAL GROUP LLC
Other - Org Name:VIDANT ENDOSCOPY CENTER-KINSTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, OPERACTIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BARHOLOMEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-847-9067
Mailing Address - Street 1:PO BOX 8423
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-8423
Mailing Address - Country:US
Mailing Address - Phone:252-847-9067
Mailing Address - Fax:252-847-7091
Practice Address - Street 1:701 DOCTORS DR STE N
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1584
Practice Address - Country:US
Practice Address - Phone:252-559-2200
Practice Address - Fax:252-522-5662
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIDANT MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0122261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical