Provider Demographics
NPI:1255598413
Name:KEITH C DAMICO PAC PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:KEITH C DAMICO PAC PROFESSIONAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-438-8577
Mailing Address - Street 1:PO BOX 3086
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28680-3086
Mailing Address - Country:US
Mailing Address - Phone:828-438-8577
Mailing Address - Fax:828-438-8507
Practice Address - Street 1:5235 NC 226 S
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8733
Practice Address - Country:US
Practice Address - Phone:828-438-8577
Practice Address - Fax:828-438-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5601658Medicaid
NC5601658Medicaid