Provider Demographics
NPI:1396003646
Name:ALBERT WHITAKER,JR. MD,PA
Entity Type:Organization
Organization Name:ALBERT WHITAKER,JR. MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-867-7494
Mailing Address - Street 1:224 S NEW HOPE RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4873
Mailing Address - Country:US
Mailing Address - Phone:704-867-7494
Mailing Address - Fax:704-867-7432
Practice Address - Street 1:224 S NEW HOPE RD
Practice Address - Street 2:SUITE K
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4873
Practice Address - Country:US
Practice Address - Phone:704-867-7494
Practice Address - Fax:704-867-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23244261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC81157Medicare UPIN