Provider Demographics
NPI:1598841868
Name:OWEN DRIVE SURGICAL CLINIC OF FAYETTEVILLE PLLC
Entity Type:Organization
Organization Name:OWEN DRIVE SURGICAL CLINIC OF FAYETTEVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BUNNY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-0101
Mailing Address - Street 1:513 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3433
Mailing Address - Country:US
Mailing Address - Phone:910-323-0101
Mailing Address - Fax:910-484-2654
Practice Address - Street 1:513 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3433
Practice Address - Country:US
Practice Address - Phone:910-323-0101
Practice Address - Fax:910-484-2654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017XCOtherBCBS
NC017XCOtherBCBS