Provider Demographics
NPI:1710942610
Name:FARMVILLE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:FARMVILLE INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:MARANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-753-3193
Mailing Address - Street 1:3485 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-1466
Mailing Address - Country:US
Mailing Address - Phone:252-753-3193
Mailing Address - Fax:252-753-7966
Practice Address - Street 1:3485 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1466
Practice Address - Country:US
Practice Address - Phone:252-753-3193
Practice Address - Fax:252-753-7966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20000090207Q00000X
NC200000090261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126A3Medicaid
NCDF6187OtherRAILROAD MEDICARE (GROUP NUMBER)
NCP00379704OtherRAILROAD MEDICARE (PIN)
NC126A3OtherBLUE CROSS BLUE SHIELD
NCP00379704OtherRAILROAD MEDICARE (PIN)
NC2336381Medicare PIN