Provider Demographics
NPI:1407977804
Name:COVENANT CLINIC, P. A.
Entity Type:Organization
Organization Name:COVENANT CLINIC, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THELLIE
Authorized Official - Middle Name:RUPERT
Authorized Official - Last Name:AINSLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:M D
Authorized Official - Phone:919-774-4163
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-2427
Mailing Address - Country:US
Mailing Address - Phone:919-774-4163
Mailing Address - Fax:
Practice Address - Street 1:7953 VILLANOW DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-7595
Practice Address - Country:US
Practice Address - Phone:919-774-4163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDN4531OtherPALMETTO GBA RAILROAD MEDICARE
NC5950617Medicaid
NC202552BMedicare ID - Type Unspecified