Provider Demographics
NPI:1669648143
Name:BLADEN HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BLADEN HEALTHCARE, LLC
Other - Org Name:CAPE FEAR VALLEY - BLADEN MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-862-5178
Mailing Address - Street 1:300 A EAST MCKAY STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337
Mailing Address - Country:US
Mailing Address - Phone:910-862-6308
Mailing Address - Fax:910-862-5501
Practice Address - Street 1:501 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9375
Practice Address - Country:US
Practice Address - Phone:910-862-6308
Practice Address - Fax:910-862-5501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLADEN HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0154207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2804523Medicare PIN