Provider Demographics
NPI:1821135773
Name:ISLAND MEDICAL CENTER
Entity Type:Organization
Organization Name:ISLAND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:COOKE
Authorized Official - Last Name:JARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-255-6005
Mailing Address - Street 1:PO BOX 2360
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-2360
Mailing Address - Country:US
Mailing Address - Phone:252-473-2500
Mailing Address - Fax:252-473-1222
Practice Address - Street 1:715 US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954-9241
Practice Address - Country:US
Practice Address - Phone:252-473-2500
Practice Address - Fax:252-473-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401185207Q00000X
NC168637363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890714LMedicaid
NC0174LOtherBLUE CROSS BLUE SHIELD