Provider Demographics
NPI:1578692703
Name:PINEHURST FOOT SPECIALIST
Entity Type:Organization
Organization Name:PINEHURST FOOT SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-751-9120
Mailing Address - Street 1:PO BOX 4839
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-4839
Mailing Address - Country:US
Mailing Address - Phone:919-751-9120
Mailing Address - Fax:919-751-9170
Practice Address - Street 1:6 REGIONAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8850
Practice Address - Country:US
Practice Address - Phone:919-751-9120
Practice Address - Fax:919-751-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC286261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890805KMedicaid
NC2431909JOtherMEDICARE INDIVIDUAL PROVIDER NUMBER
NC2431909JMedicare ID - Type UnspecifiedGROUP
NC890805KMedicaid