Provider Demographics
NPI:1154693695
Name:PASSPORT HEALTH PC
Entity type:Organization
Organization Name:PASSPORT HEALTH PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-781-0053
Mailing Address - Street 1:8450 CHAPEL HILL RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4577
Mailing Address - Country:US
Mailing Address - Phone:919-781-0053
Mailing Address - Fax:919-481-0455
Practice Address - Street 1:100 PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:RESEARCH TRIANGLE PARK
Practice Address - State:NC
Practice Address - Zip Code:27709-0165
Practice Address - Country:US
Practice Address - Phone:919-781-0053
Practice Address - Fax:919-481-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001186261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service