Provider Demographics
NPI:1417071283
Name:BLADEN EAST MEDICAL
Entity Type:Organization
Organization Name:BLADEN EAST MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CARVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-669-2221
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:COUNCIL
Mailing Address - State:NC
Mailing Address - Zip Code:28434-0186
Mailing Address - Country:US
Mailing Address - Phone:910-669-2221
Mailing Address - Fax:
Practice Address - Street 1:16860 NC HIGHWAY 87 E
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:NC
Practice Address - Zip Code:28434-8738
Practice Address - Country:US
Practice Address - Phone:910-669-2226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015T6Medicaid