Provider Demographics
NPI:1104816396
Name:EDENTON INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:EDENTON INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HASKETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-482-5171
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1210
Mailing Address - Country:US
Mailing Address - Phone:252-482-5171
Mailing Address - Fax:252-482-5173
Practice Address - Street 1:104 MARK DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1756
Practice Address - Country:US
Practice Address - Phone:252-482-5171
Practice Address - Fax:252-482-5173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890127HMedicaid
NC1297Medicare ID - Type Unspecified