Provider Demographics
NPI:1154436012
Name:BLADEN HEALTHCARE LLC
Entity type:Organization
Organization Name:BLADEN HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AYUB
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:910-615-6994
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-0398
Mailing Address - Country:US
Mailing Address - Phone:910-862-3212
Mailing Address - Fax:910-862-2263
Practice Address - Street 1:507 DOCTOR'S DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-3212
Practice Address - Fax:910-862-2263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLADEN HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967555Medicaid
NC2351500Medicare PIN
NC201418Medicare PIN
D26803Medicare UPIN