Provider Demographics
NPI:1316098023
Name:TRUESDALE, STEPHEN GREGORY (CPO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GREGORY
Last Name:TRUESDALE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4153 HEARTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412
Mailing Address - Country:US
Mailing Address - Phone:919-995-9491
Mailing Address - Fax:919-995-9491
Practice Address - Street 1:405 W 15TH ST
Practice Address - Street 2:201
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3524
Practice Address - Country:US
Practice Address - Phone:252-940-1203
Practice Address - Fax:252-940-1206
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795069Medicaid
NC0482POtherBCBS
NC1386842193Medicare NSC
NC7795069Medicaid
VA1760583033Medicare NSC
NC0482POtherBCBS