Provider Demographics
NPI:1679767750
Name:RUDOLPH I MINTZ JR
Entity Type:Organization
Organization Name:RUDOLPH I MINTZ JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:I
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-527-5500
Mailing Address - Street 1:400 GLENWOOD AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3851
Mailing Address - Country:US
Mailing Address - Phone:252-527-5500
Mailing Address - Fax:252-527-4875
Practice Address - Street 1:400 GLENWOOD AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3851
Practice Address - Country:US
Practice Address - Phone:252-527-5500
Practice Address - Fax:252-527-4875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC208915AMedicare PIN