Provider Demographics
NPI:1518014901
Name:LUMBERTON MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:LUMBERTON MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BODIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-739-7551
Mailing Address - Street 1:395 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3018
Mailing Address - Country:US
Mailing Address - Phone:910-739-7551
Mailing Address - Fax:910-739-2332
Practice Address - Street 1:395 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3018
Practice Address - Country:US
Practice Address - Phone:910-739-7551
Practice Address - Fax:910-739-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133Y2Medicaid
NC8971550Medicaid
NC8952432Medicaid
NC8921108Medicaid
NC8914154Medicaid
NC8928375Medicaid
NC8914154Medicaid
NCC81986Medicare UPIN
NC8928375Medicaid
NC203921BMedicare ID - Type Unspecified
NCF39882Medicare UPIN
NC205903Medicare ID - Type Unspecified
NCC82159Medicare UPIN
NCC83521Medicare UPIN
NC2022442Medicare ID - Type Unspecified
NC8952432Medicaid
NC89133Y2Medicaid
NC230395Medicare PIN
NCH62251Medicare UPIN
NC203649BMedicare ID - Type Unspecified
NCH95301Medicare UPIN