Provider Demographics
NPI:1457482531
Name:HALIFAX MEDICAL SERVICES PA
Entity Type:Organization
Organization Name:HALIFAX MEDICAL SERVICES PA
Other - Org Name:MEDICAL CLINIC OF PINETOPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HUME
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C,MPH
Authorized Official - Phone:252-827-1550
Mailing Address - Street 1:105-C SOUTHWEST FIRST ST
Mailing Address - Street 2:PO BOX 685
Mailing Address - City:PINETOPS
Mailing Address - State:NC
Mailing Address - Zip Code:27864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 SOUTHWEST FIRST STREET
Practice Address - Street 2:
Practice Address - City:PINETOPS
Practice Address - State:NC
Practice Address - Zip Code:27864
Practice Address - Country:US
Practice Address - Phone:252-827-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HALIFAX MEDICAL SERVICES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68222261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC348950A&CMedicaid
NC348950Medicare Oscar/Certification