Provider Demographics
NPI:1962509372
Name:PINEHURST MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:PINEHURST MEDICAL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:ENFINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-235-3004
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:910-235-3443
Practice Address - Street 1:200 PAVILION WAY
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4561
Practice Address - Country:US
Practice Address - Phone:910-639-9088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39578291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001306Medicaid
690003763OtherPALMETTO GBA (R/R MCR)
FH6600055OtherFIRSTCAROLINACARE
02418OtherBC/BS NC
02418OtherBC/BS NC
NC7001306Medicaid