Provider Demographics
NPI:1982913422
Name:SCOTLAND REGIONAL HEALTH NETWORK
Entity Type:Organization
Organization Name:SCOTLAND REGIONAL HEALTH NETWORK
Other - Org Name:WAGRAM FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PRACHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-291-7920
Mailing Address - Street 1:PO BOX 602458
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2458
Mailing Address - Country:US
Mailing Address - Phone:910-369-3136
Mailing Address - Fax:910-369-4756
Practice Address - Street 1:24420 MARLBORO STREET
Practice Address - Street 2:
Practice Address - City:WAGRAM
Practice Address - State:NC
Practice Address - Zip Code:28396-9600
Practice Address - Country:US
Practice Address - Phone:919-369-3136
Practice Address - Fax:910-369-4756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTLAND REGIONAL HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB433Medicaid
NC1982913422Medicaid
NC5916876Medicaid
SCNPB433Medicaid