PORT HEALTH SERVICES

Provider Demographics

• NPI: 1477538254
• Name: PORT HEALTH SERVICES
• Entity type: Organization
• Organization Name: PORT HEALTH SERVICES
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: CREDENTIALING MANAGER
• Authorized Official - First Name: BRETT
• Authorized Official - Last Name: BEAVERS
• Authorized Official - Phone: 919-210-7661
• Mailing Address - Street 1: 4300 SAPPHIRE CT STE 110
• Mailing Address - City: GREENVILLE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 27834-9079
• Mailing Address - Country: US
• Mailing Address - Phone: 252-830-7540
• Mailing Address - Fax: 252-413-0932
• Practice Address - Street 1: 2602 COURTIER DR
• Practice Address - City: GREENVILLE
• Practice Address - State: NC
• Practice Address - Zip Code: 27834-7818
• Practice Address - Country: US
• Practice Address - Phone: 252-752-0483
• Practice Address - Fax: 252-757-3172
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-12-14
• Last Update Date: 2023-05-24

Provider Licenses

State	License ID	Taxonomies
		251S00000X, 261QC1500X, 291U00000X
NC	MHL-074-145	3245S0500X
NC	MHL-074-157	101Y00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	101Y00000X	Behavioral Health & Social Service Providers	Counselor		Group - Multi-Specialty
No	251S00000X	Agencies	Community/Behavioral Health		Group - Multi-Specialty
No	261QC1500X	Ambulatory Health Care Facilities	Clinic/Center	Community Health	Group - Multi-Specialty
No	291U00000X	Laboratories	Clinical Medical Laboratory
No	3245S0500X	Residential Treatment Facilities	Substance Abuse Rehabilitation Facility	Substance Abuse Treatment, Children

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	6005329	Medicaid
NC	6005332	Medicaid
NC	6005334	Medicaid
NC	6005597	Medicaid
NC	6603789	Medicaid
NC	016X5	Other	BCBS PROVIDER NUMBER
NC	6005592	Medicaid
NC	5900726	Medicaid
NC	5900727	Medicaid
NC	6603790	Medicaid
NC	6603789	Medicaid
NC	5900727	Medicaid