Provider Demographics
NPI:1437315165
Name:NORTH CAROLINA SHOULDER AND ELBOW SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:NORTH CAROLINA SHOULDER AND ELBOW SURGERY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:YEARGAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:910-454-0010
Mailing Address - Street 1:900 NORTH HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461
Mailing Address - Country:US
Mailing Address - Phone:910-454-0010
Mailing Address - Fax:
Practice Address - Street 1:900 NORTH HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461
Practice Address - Country:US
Practice Address - Phone:910-454-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6201340001Medicare NSC