Provider Demographics
NPI:1528365657
Name:SOUTHPORT INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:SOUTHPORT INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:HILTZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:910-457-9127
Mailing Address - Street 1:PO BOX 10922
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-0922
Mailing Address - Country:US
Mailing Address - Phone:910-457-9127
Mailing Address - Fax:910-269-2884
Practice Address - Street 1:1513 N HOWE ST
Practice Address - Street 2:UNIT 6
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-2769
Practice Address - Country:US
Practice Address - Phone:910-457-9127
Practice Address - Fax:910-269-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC201101100100-1OtherDEPT OF THE SECRETARY OF STATE CERTIFICATION NUMBER
NC34D0246020OtherCLIA WAIVED CERTIFICATE
NC11502Medicare PIN