Provider Demographics
NPI:1699722272
Name:PRODIGY HEALTHCARE SERVICES INC.
Entity type:Organization
Organization Name:PRODIGY HEALTHCARE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELECHI
Authorized Official - Middle Name:C
Authorized Official - Last Name:UWAKWE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:919-264-9769
Mailing Address - Street 1:4801 HARGROVE ROAD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-1949
Mailing Address - Country:US
Mailing Address - Phone:919-264-9769
Mailing Address - Fax:919-341-5838
Practice Address - Street 1:4801 HARGROVE ROAD
Practice Address - Street 2:SUITE 12
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-1949
Practice Address - Country:US
Practice Address - Phone:919-264-9769
Practice Address - Fax:919-341-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704536Medicaid
NC5744490001Medicare NSC