Provider Demographics
NPI:1558450247
Name:TODDS NORTHSIDE PROFESSIONAL PCHY
Entity type:Organization
Organization Name:TODDS NORTHSIDE PROFESSIONAL PCHY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TWIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-331-1333
Mailing Address - Street 1:PO BOX 1448
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27906-1448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:STE A1
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-331-1333
Practice Address - Fax:252-331-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
NC05351333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0155036Medicaid
3428174OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0462900001Medicare ID - Type Unspecified