Provider Demographics
NPI:1245267293
Name:NOVA URGENT CARE PAMLICO PA
Entity type:Organization
Organization Name:NOVA URGENT CARE PAMLICO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-672-0095
Mailing Address - Street 1:1813 S GLENBURNIE RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5210
Mailing Address - Country:US
Mailing Address - Phone:252-672-0095
Mailing Address - Fax:252-672-9897
Practice Address - Street 1:13808 HWY 55
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NC
Practice Address - Zip Code:28509
Practice Address - Country:US
Practice Address - Phone:252-745-7440
Practice Address - Fax:252-672-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X, 363L00000X, 261QU0200X
NC001000560363A00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903188Medicaid
NC2324658OtherMEDICARE GROUP ID NUMBER
NC5903188Medicaid