Provider Demographics
NPI:1891960241
Name:PINE HAVEN FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:PINE HAVEN FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SLATOSKY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:336-498-1200
Mailing Address - Street 1:604 WEST ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317
Mailing Address - Country:US
Mailing Address - Phone:336-498-1200
Mailing Address - Fax:336-498-1206
Practice Address - Street 1:604 WEST ACADEMY ST
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317
Practice Address - Country:US
Practice Address - Phone:336-498-1200
Practice Address - Fax:336-498-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891212UMedicaid
NC2348546OtherMEDICARE
H02774Medicare UPIN
NC891212UMedicaid