Provider Demographics
NPI:1477538254
Name:PORT HEALTH SERVICES
Entity Type:Organization
Organization Name:PORT HEALTH SERVICES
Other - Org Name:PORT HUMAN SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-210-7661
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:2602 COURTIER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7818
Practice Address - Country:US
Practice Address - Phone:252-752-0483
Practice Address - Fax:252-757-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-074-157101Y00000X
251S00000X, 261QC1500X, 291U00000X
NCMHL-074-1453245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No291U00000XLaboratoriesClinical Medical Laboratory
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005329Medicaid
NC6005332Medicaid
NC6005334Medicaid
NC6005597Medicaid
NC6603789Medicaid
NC016X5OtherBCBS PROVIDER NUMBER
NC6005592Medicaid
NC5900726Medicaid
NC5900727Medicaid
NC6603790Medicaid
NC6603789Medicaid
NC5900727Medicaid