Provider Demographics
NPI:1982754370
Name:PORT HEALTH SERVICES
Entity Type:Organization
Organization Name:PORT HEALTH SERVICES
Other - Org Name:PORT HUMAN SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REIMBURSEMENT MANGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:ROUNTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-830-7540
Mailing Address - Street 1:4300-110 SAPPHIRE COURT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-752-0483
Mailing Address - Fax:252-752-2971
Practice Address - Street 1:417 E GRANTHAM RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-6881
Practice Address - Country:US
Practice Address - Phone:252-633-6431
Practice Address - Fax:252-251-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-025-041251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300529Medicaid