Provider Demographics
NPI:1982797072
Name:FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC
Entity Type:Organization
Organization Name:FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAUTAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-678-8611
Mailing Address - Street 1:1205 CAPE CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4404
Mailing Address - Country:US
Mailing Address - Phone:910-678-8611
Mailing Address - Fax:910-678-8100
Practice Address - Street 1:1205 CAPE CT
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4404
Practice Address - Country:US
Practice Address - Phone:910-678-8611
Practice Address - Fax:910-678-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-01525207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890134JMedicaid
NC0134JOtherBLUE CROSS
NC0134JOtherBLUE CROSS
NC890134JMedicaid