Provider Demographics
NPI:1922131200
Name:NORTH CAROLINA MOBILE ULTRASOUND
Entity Type:Organization
Organization Name:NORTH CAROLINA MOBILE ULTRASOUND
Other - Org Name:NCMU
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DARRYL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:800-983-9840
Mailing Address - Street 1:2554 LEWISVILLE-CLEMMONS ROAD
Mailing Address - Street 2:SUITE 201, BOX 11
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8110
Mailing Address - Country:US
Mailing Address - Phone:800-983-9840
Mailing Address - Fax:336-245-2017
Practice Address - Street 1:2554 LEWISVILLE-CLEMMONS ROAD
Practice Address - Street 2:SUITE 201, BOX 11
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8110
Practice Address - Country:US
Practice Address - Phone:800-983-9840
Practice Address - Fax:336-245-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085U0001X
335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8105017Medicaid
NC2881795Medicare ID - Type UnspecifiedMOBILE ULTRASOUND
NC8105017Medicaid