Provider Demographics
NPI:1922091115
Name:PROVOSTY, GEORGE HURST (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:HURST
Last Name:PROVOSTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1527
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1527
Mailing Address - Country:US
Mailing Address - Phone:910-738-8222
Mailing Address - Fax:910-671-0846
Practice Address - Street 1:209 WEST 27TH STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3016
Practice Address - Country:US
Practice Address - Phone:910-738-8222
Practice Address - Fax:910-671-0846
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000181352085R0202X
NC181352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC69325OtherBLUE CROSS BLUE SHIELD
NC8969325Medicaid
E61536Medicare UPIN
NC8969325Medicaid