Provider Demographics
NPI:1598916777
Name:CAPE FEAR OTOLARYNGOLOGY, PA
Entity type:Organization
Organization Name:CAPE FEAR OTOLARYNGOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-9222
Mailing Address - Street 1:2053 VALLEYGATE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3688
Mailing Address - Country:US
Mailing Address - Phone:910-323-9222
Mailing Address - Fax:910-221-9220
Practice Address - Street 1:2053 VALLEYGATE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-323-9222
Practice Address - Fax:910-221-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001503Medicaid