Provider Demographics
NPI:1740463140
Name:SOUTH WHITEVILLE URGENT CARE & FAMILY PRACTICE PA
Entity type:Organization
Organization Name:SOUTH WHITEVILLE URGENT CARE & FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-642-9876
Mailing Address - Street 1:326 COLUMBUS CORNERS DR
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-4929
Mailing Address - Country:US
Mailing Address - Phone:910-642-9876
Mailing Address - Fax:910-642-9879
Practice Address - Street 1:308 US HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-7828
Practice Address - Country:US
Practice Address - Phone:910-264-2334
Practice Address - Fax:866-251-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015U2Medicaid
NC89015U2Medicaid