Provider Demographics
NPI:1467619817
Name:LITTLE RIVER MED 1 PA
Entity Type:Organization
Organization Name:LITTLE RIVER MED 1 PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCASKILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:919-736-0767
Mailing Address - Street 1:210 N HERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-3810
Mailing Address - Country:US
Mailing Address - Phone:919-736-0767
Mailing Address - Fax:919-580-0148
Practice Address - Street 1:210 N HERMAN ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-3810
Practice Address - Country:US
Practice Address - Phone:919-736-0767
Practice Address - Fax:919-580-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty