Provider Demographics
NPI:1699880971
Name:PUNGO FAMILY MEDICINE PA
Entity type:Organization
Organization Name:PUNGO FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEAMER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-944-2218
Mailing Address - Street 1:245 ALLEN STREET
Mailing Address - Street 2:
Mailing Address - City:BELHAVEN
Mailing Address - State:NC
Mailing Address - Zip Code:27810-1405
Mailing Address - Country:US
Mailing Address - Phone:252-944-2218
Mailing Address - Fax:252-943-2377
Practice Address - Street 1:245 ALLEN STREET
Practice Address - Street 2:
Practice Address - City:BELHAVEN
Practice Address - State:NC
Practice Address - Zip Code:27810-1405
Practice Address - Country:US
Practice Address - Phone:252-944-2218
Practice Address - Fax:252-943-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8914095Medicaid
NC017C5OtherBCBS
NC2330772Medicare ID - Type Unspecified