Provider Demographics
NPI:1417049867
Name:FIFTH AVENUE INTERNAL MEDICINE AND GERIATRICS PA
Entity Type:Organization
Organization Name:FIFTH AVENUE INTERNAL MEDICINE AND GERIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-693-6566
Mailing Address - Street 1:724 FIFTH AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739
Mailing Address - Country:US
Mailing Address - Phone:828-693-6566
Mailing Address - Fax:828-693-6765
Practice Address - Street 1:724 FIFTH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739
Practice Address - Country:US
Practice Address - Phone:828-693-6566
Practice Address - Fax:828-693-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103068207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8941202Medicaid
NC8941202Medicaid