Provider Demographics
NPI:1417378779
Name:SURGICAL MEDICAL CLINIC
Entity type:Organization
Organization Name:SURGICAL MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NASEEM
Authorized Official - Middle Name:H
Authorized Official - Last Name:NASRALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-259-2161
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-0729
Mailing Address - Country:US
Mailing Address - Phone:910-259-2161
Mailing Address - Fax:910-259-7870
Practice Address - Street 1:407 EAST FREMONT STREET
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-0729
Practice Address - Country:US
Practice Address - Phone:910-259-2161
Practice Address - Fax:910-259-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19763208600000X
NC5005024363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7961886Medicaid
NC1235445982OtherNC MEDICARE AND MEDICAID # PENDING FOR NPI # 1235445982
NCB65117Medicare UPIN
NC7961886Medicaid