Provider Demographics
NPI:1437102829
Name:OUTER BANKS HEMATOLOGY ONCOLOGY PA
Entity Type:Organization
Organization Name:OUTER BANKS HEMATOLOGY ONCOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ACOSTAMADIEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-480-4699
Mailing Address - Street 1:PO BOX 2288
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-2288
Mailing Address - Country:US
Mailing Address - Phone:252-480-4699
Mailing Address - Fax:252-480-3280
Practice Address - Street 1:4810 S CROATAN HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-8508
Practice Address - Country:US
Practice Address - Phone:252-480-4699
Practice Address - Fax:252-480-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDE2252OtherRR MEDICARE
NC89126U6Medicaid
NCDE2252OtherRR MEDICARE