Provider Demographics
NPI:1710609276
Name:PINEHURST SURGICAL CLINIC, PA
Entity Type:Organization
Organization Name:PINEHURST SURGICAL CLINIC, PA
Other - Org Name:PINEHURST SURGICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:RICHARDSON
Authorized Official - Last Name:HEFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-235-2711
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-2000
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:910-295-0244
Practice Address - Street 1:3716 MORGANTON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4963
Practice Address - Country:US
Practice Address - Phone:910-302-8026
Practice Address - Fax:910-420-1988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINEHURST SURGICAL CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890297EMedicaid