Provider Demographics
NPI:1285781740
Name:PAMLICO MEDICAL CENTER PA
Entity type:Organization
Organization Name:PAMLICO MEDICAL CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-249-2888
Mailing Address - Street 1:PO BOX 1058
Mailing Address - Street 2:
Mailing Address - City:ORIENTAL
Mailing Address - State:NC
Mailing Address - Zip Code:28571-1058
Mailing Address - Country:US
Mailing Address - Phone:252-249-2888
Mailing Address - Fax:252-249-3166
Practice Address - Street 1:901 BROAD ST
Practice Address - Street 2:
Practice Address - City:ORIENTAL
Practice Address - State:NC
Practice Address - Zip Code:28571
Practice Address - Country:US
Practice Address - Phone:252-249-2888
Practice Address - Fax:252-249-3166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAMLICO MEDICAL CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-05
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902364Medicaid
NC02364OtherBLUE CROSS BLUE SHIELD
NC2309835AMedicare PIN
NC8902364Medicaid