Provider Demographics
NPI:1407902059
Name:GENERATIONS FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:GENERATIONS FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:984-333-2741
Mailing Address - Street 1:1021 DARRINGTON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8158
Mailing Address - Country:US
Mailing Address - Phone:919-852-3999
Mailing Address - Fax:919-825-3444
Practice Address - Street 1:1021 DARRINGTON DR STE 101
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8158
Practice Address - Country:US
Practice Address - Phone:919-852-3999
Practice Address - Fax:919-825-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
207Q00000X
NC28064305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA50138Medicare UPIN