Provider Demographics
NPI:1679571574
Name:BECKFORD AVENUE MEDICAL CENTER PA
Entity Type:Organization
Organization Name:BECKFORD AVENUE MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-492-2161
Mailing Address - Street 1:176 BECKFORD DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2589
Mailing Address - Country:US
Mailing Address - Phone:252-492-2161
Mailing Address - Fax:252-438-2888
Practice Address - Street 1:176 BECKFORD DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2589
Practice Address - Country:US
Practice Address - Phone:252-492-2161
Practice Address - Fax:252-438-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901092Medicaid
NC0656Medicare PIN
NC8901092Medicaid