Provider Demographics
NPI:1477784080
Name:WOMENS HEALTH HAVEN OBSTETRICS AND GYNECOLOGY
Entity type:Organization
Organization Name:WOMENS HEALTH HAVEN OBSTETRICS AND GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DORRETTE
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-799-1667
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:217-799-1667
Mailing Address - Fax:866-376-8277
Practice Address - Street 1:2573 RAVENHILL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5451
Practice Address - Country:US
Practice Address - Phone:910-488-7548
Practice Address - Fax:910-339-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912032Medicaid
NC5912032Medicaid