Provider Demographics
NPI:1821499716
Name:COLUMBUS INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:COLUMBUS INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:MINU
Authorized Official - Last Name:FERNZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-642-3356
Mailing Address - Street 1:626 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3708
Mailing Address - Country:US
Mailing Address - Phone:910-642-3356
Mailing Address - Fax:910-642-5433
Practice Address - Street 1:626 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3708
Practice Address - Country:US
Practice Address - Phone:910-642-3356
Practice Address - Fax:910-642-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0096-00530207R00000X
NC00100831363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891051NMedicaid