Provider Demographics
NPI:1316298458
Name:SAMPSON REGIONAL PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:SAMPSON REGIONAL PROFESSIONAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLTZGLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-590-8755
Mailing Address - Street 1:607 BEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2603
Mailing Address - Country:US
Mailing Address - Phone:910-590-8755
Mailing Address - Fax:910-596-6106
Practice Address - Street 1:518 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2602
Practice Address - Country:US
Practice Address - Phone:910-596-4288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301024174400000X
207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00492OtherBCBS
NCH88013Medicare UPIN