Provider Demographics
NPI:1396886842
Name:BERTIE COUNTY RURAL HEALTH ASSOCIATION
Entity type:Organization
Organization Name:BERTIE COUNTY RURAL HEALTH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAVONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:252-794-1835
Mailing Address - Street 1:P.O. BOX 628
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-0628
Mailing Address - Country:US
Mailing Address - Phone:252-794-3042
Mailing Address - Fax:252-794-2911
Practice Address - Street 1:104 RHODES AVENUE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9656
Practice Address - Country:US
Practice Address - Phone:252-794-3042
Practice Address - Fax:252-794-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344512AMedicaid
NC341825OtherMEDICARE
NC344512CMedicaid
NC341825Medicare Oscar/Certification