Provider Demographics
NPI:1255397725
Name:CAPE FEAR REGIONAL UROLOGICAL
Entity type:Organization
Organization Name:CAPE FEAR REGIONAL UROLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-485-8801
Mailing Address - Street 1:1537 OWEN PARK LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3454
Mailing Address - Country:US
Mailing Address - Phone:910-485-8801
Mailing Address - Fax:910-485-5605
Practice Address - Street 1:1537 OWEN PARK LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3454
Practice Address - Country:US
Practice Address - Phone:910-485-8801
Practice Address - Fax:910-485-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400496208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901823Medicaid
NC0335Medicare ID - Type UnspecifiedMCX PROVIDER NO