Provider Demographics
NPI:1417919390
Name:FAYETTEVILLE ORTHOPAEDIC CLINIC, PA
Entity Type:Organization
Organization Name:FAYETTEVILLE ORTHOPAEDIC CLINIC, PA
Other - Org Name:FAYETTEVILLE ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-223-2007
Mailing Address - Street 1:1991 FORDHAM DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304
Mailing Address - Country:US
Mailing Address - Phone:910-484-3114
Mailing Address - Fax:910-484-8824
Practice Address - Street 1:1991 FORDHAM DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3650
Practice Address - Country:US
Practice Address - Phone:910-484-3114
Practice Address - Fax:910-484-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901555Medicaid
NC0314090001Medicare NSC
NC0295Medicare ID - Type Unspecified